Method and system for automated medical records processing

ABSTRACT

A method and system for automated medical records processing. The method and system includes plural electronic medical templates specifically designed such that they reduce the complexity and risk associated with collecting patient encounter information, creating a medical diagnosis and help generate the appropriate number and type medical codes for a specific type of medical practice when processed. The medical codes and other types of processed patient encounter information are displayed in real-time on electronic medical records and invoices immediately after a patient encounter.

CROSS REFERENCES TO RELATED APPLICATIONS

This U.S. Utility patent application is a Continuation-In-Part (CIP) of U.S. Utility patent application Ser. No. 10/692,976, filed on Oct. 24, 2003, that claims priority from U.S. Provisional patent application No. 60/422,083, filed on Oct. 29, 2002, which issued as U.S. Pat. No. 7,624,027, on Nov. 24, 2009, the contents of all of which are incorporated herein by reference.

COPYRIGHT NOTICE

Pursuant to 37 C.F.R. 1.71(e), applicants note that a portion of this disclosure contains material that is subject to and for which is claimed copyright protection, such as, but not limited to, copies of paper forms, screen shots, user interfaces, electronic medical record formats, or any other aspects of this submission for which copyright protection is or may be available in any jurisdiction. The copyright owner has no objection to the facsimile reproduction by anyone of the patent document or patent disclosure, as it appears in the Patent Office patent file or records. All other rights are reserved, and all other reproduction, distribution, creation of derivative works based on the contents, public display, and public performance of the application or any part thereof are prohibited by applicable copyright law.

FIELD OF THE INVENTION

This invention relates to medical records and information. More specifically, it relates to a method and system for automated medical records processing.

BACKGROUND OF THE INVENTION

There are many different types of medical information that are routinely collected when a patient has an emergency or non-emergency medical problem, or visit a provider for a routine visit or annual physical. The medical information includes such information as current symptoms the patient is feeling, any medication the patient is currently taking, any past medical problems or surgeries the patient has, known allergies, family history, prescribed medications, etc.

Such medical information is typically recorded manually on paper forms by medical staff, nurses and/or providers. The medical information may also be dictated by a provider and later transcribed to another form by a medical transcriptionist.

The American Medical Association (“AMA”) has developed a system of codes for medical and surgical procedures, diagnostic tests, laboratory studies, and other provider medical services rendered to patients. This system of codes is referred to as Current Procedural Terminology, (“CPT”) codes. CPT codes provide a uniform language that details medical, surgical, and diagnostic services utilized by providers to communicate to third-party payors for the services that are rendered.

The CPT codes were first developed by the AMA in 1966. Each year, an annual publication is prepared by the AMA that includes CPT code changes corresponding with updates in medical technology and practice. The 2003 version of CPT codes, for example, CPT 2003, includes over 8,000 codes and descriptors. The CPT code set also include a set of modifiers that may be used to further define CPT codes.

Evaluation and Management (E/M) codes are a sub-set of the CPT codes that are used to describe a patient's encounter in a provider's office, hospital or other medical setting. E/M codes are used to describe the level of care a provider renders to a patient.

The CPT and E/M codes are assigned numeric codes that used to classify the information, categorize and organize the information and used to generate revenue for the organization that employs the medical personnel. The numeric codes may also include codes used by insurance companies or other types of organizations such as health organizations such as those responsible for communicable diseases. Additional information on the AMA CPT and E/M codes can be obtained on the Internet at the Universal Resource Locator (“URL”) “www.ama-assn.org.”

The Health Care Finance Administration (“HCFA”), a U.S. government agency responsible for the operation of oversight of medical insurance programs such as Medicare and Medicaid, has also developed a set of medical codes and modifiers. The HCFA developed a set of medical codes called Health Care Procedural Coding System (“HCPCS”) codes to help relate CPT codes to medical billing. The HCFA was renamed the Centers for Medicare & Medicaid Services (CMS) on Jun. 14, 2001. Additional information on the HCFA HCPCS codes can be found on the Internet at the URL “cms.hhs.gov.”

In addition, the World Health Organization (“WHO”) also developed a similar set of codes to identify medical diagnoses, conditions and injuries. These codes are called International Classification of Diseases 9th edition Clinical Modification (“ICD-9”) codes and International Classifications 10^(th) edition Clinical Modification (“ICD-10”) can be found on the internet at the URL “www.who.org”. ICD-10 codes for both diagnoses and procedures have been developed, but are not yet used in the USA.

Accurate and proper coding of medical information is important because it helps determine financial reimbursement for physician services. It is also important to ensure compliance with state and federal regulations as well as help protect physicians from the financial and legal ramifications of government, insurance company and other types of audits.

There are many problems associated with the collection and recording medical information. One problem is that incorrect medical coding creates both a revenue generation problem and a compliance problem for many physician practices.

For example, one study by Mitchell S. King, Lisa Sharp, and Martin S. Lipsky, entitled “Accuracy of CPT evaluation and management coding by family physicians,” and published in the Journal of American Board of Family Practice 14(3):184-192, 2001, has shown that family physicians tend to generate lower-level E/M codes for established patients, thereby “undercoding” the established patient visit. The undercoding results in a loss of potential revenues. Investigative agencies may also classify this practice as fraudulent, in that it may be construed to indicate that the provider is reducing fees by undercoding, and thereby attempting to entice patients to visit more frequently.

These same family physicians also tend to generate higher-level E/M codes than necessary for new patients, thereby “overcoding” the new patient visit. This results in rejection of insurance payments and could result in loss of revenue, insurance audits and potential prosecution under the Federal False Claims Act (“FFCA”), 31 U.S.C. 3729 or other Federal and state laws used prevent fraudulent insurance claims.

Another problem is that incorrect or improper coding of medical information could result in non-compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) 42 U.S.C. 1320d, et. seq. and other Federal and state laws enacted to protect privacy.

Another problem is that medical organizations use many different types of medical codes from many different types of medical organizations on many different types of proprietary and public medical forms. The medical information is typically manually re-handled several times by several different types of people (e.g., providers, nurses, medical billing specialist, etc.) with different expertise levels with respect to coding of medical information. This handling may introduce errors for the coding of medical information at many different levels.

Another problem is that the medical information is often manually entered into a data processing system. A medical technician with knowledge of medical information and medical codes must process the information to assign the proper codes. As was described above, there are typically multiple sets of medical codes such as those used for diagnosis, billing, insurance, etc. that are routinely used and changed on a periodic basis. This may also introduce errors for the coding of medical information at many different levels.

Another problem is that it typically takes a significant amount of time to process medical information and create the proper medical codes from a patient encounter. This often leads to a very slow revenue stream for physicians and a large amount of frustration for patients.

There have been attempts to solve one or more of the problems associated with coding medical information. For example, U.S. Pat. No. 6,529,876 to Dart et al. entitled “Electronic template medical records coding system” describes a method and a computer program for use by health care providers for the production of accurate billing coding for care entered using established E/M codes.”

U.S. Pat. No. 6,393,404 to Waters, et al. entitled “System and method for optimizing medical diagnosis, procedures and claims using a structured search space” describes a system and method for optimizing medical diagnosis, procedures and reimbursement claims using a structured search space.”

U.S. Pat. No. 6,208,973 to Boyer, et al. entitled “Point of service third party financial management vehicle for the healthcare industry” describes a point of service third party adjudicated payment system and method which provides for the creation of an adjudicated settlement transaction at a point of service which designates the portion of the service to be paid by the third party payor and the portion to be paid by the customer.”

U.S. Pat. No. 5,664,109, to Johnson et al. entitled “Method for extracting pre-defined data items from medical service records generated by health care providers,” described “a central medical record repository for a managed health care organization accepts and stores medical record documents in any format from medical service providers. The repository then identifies the document using information automatically extracted from the document and stores the extracted data in a document database. The repository links the document to a patient by extracting from the document demographic data identifying the patient and matching it to data stored in a patient database. Data is extracted automatically from medical records containing ‘unstructured’ or free-form text by identifying conventional organization components in the text and is organized by executing rules that extract data with the aid of such information. Documents for a patient are retrieved by identifying the patient using demographic data.”

U.S. Pat. No. 5,483,443 to Milstein, et al. entitled “Method for computing current procedural terminology codes from physician generated documentation” describes a process for calculating a Current Procedural Terminology (“CPT”) code from input received from a physician or other medical professional.”

Newman and Weller in a paper entitled “A Desk Supporting Computer-based Interaction with Paper Documents,” ACM 0-89791-513-5/92/005-0587, Chicago, May 3-7, 1992, teaches accepting input from paper forms into a computer via an interface apparatus.

However, these inventions do not solve all of the problems associated with coding medical information. Thus, it would be desirable to help reduce the complexity of collecting patient encounter information and allow easy automated collection, processing and recording of medical information codes such as diagnosis codes, billing codes, insurance codes, etc. It is also desirable to provide such medical codes in real-time during or shortly after an encounter with a patient.

SUMMARY OF THE INVENTION

In accordance with preferred embodiments of the present invention, some of the problems associated with processing medical records are overcome. A method and system for automated medical records processing is presented.

The method and system includes plural electronic templates specifically designed such that they may help reduce a complexity and risk associated with collecting patient encounter information and helps generate an appropriate type and number medical codes for a specific type of medical practice when processed.

The method and system also includes real-time processing applications that may allow easy and automated collection, processing, displaying and recording of medical codes (e.g., diagnosis codes, billing codes, insurance codes, etc.).

The foregoing and other features and advantages of preferred embodiments of the invention will be more readily apparent from the following detailed description. The detailed description proceeds with references to the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

Preferred embodiments of the present invention are described with reference to the following drawings, wherein:

FIG. 1 is a block diagram illustrating an exemplary medical records system;

FIGS. 2A and 2B are block diagrams illustrating a front side and a back side of an exemplary paper medical information template;

FIGS. 2C and 2D are a block diagram illustrating a front side and a back side of another exemplary paper medical information form that further illustrates an exemplary coding summary produced from exemplary patient encounter information;

FIGS. 2A-2D, FIGS. 8-12 are copyright © 2001-2003 by Practice Velocity, LLC. All rights reserved;

FIG. 3 is a block diagram illustrating portions of the exemplary paper medical information template of FIG. 2;

FIG. 4 is a block diagram illustrating an exemplary data flow for the medical records system of FIG. 1 for a paper medical information template;

FIG. 5 is a block diagram illustrating an exemplary data flow for the medical records system of FIG. 1 for an electronic medical information template;

FIG. 6 is a flow diagram illustrating a method of processing medical information templates via the medical records system;

FIG. 7 is flow diagram illustrating a method of processing medical information templates via the medical records system;

FIG. 8 is a block diagram illustrating an exemplary HX matrix;

FIG. 9 is a block diagram illustrating an exemplary PX matrix;

FIG. 10 is a block diagram illustrating an exemplary CX matrix;

FIG. 11 is a block diagram illustrating an exemplary final E/M matrix for a new outpatient;

FIG. 12 is a block diagram illustrating an exemplary final E/M matrix for an established outpatient;

FIG. 13 is a flow diagram illustrating a method of processing medical information templates via the medical records system;

FIG. 14 is a flow diagram illustrating a method of processing medical information templates via the medical records system;

FIG. 15 is a block diagram illustrating a 360° real-time view of a patient encounter;

FIG. 16 is a flow diagram illustrating a method for automated processing of medical information;

FIGS. 17-23 are copyright © by Practice Velocity, LLC. All rights reserved;

FIG. 17 is a block diagram of a screen shot of a first portion of an exemplary electronic medical information template;

FIG. 18 is a block diagram of a screen shot of a second portion of an exemplary electronic medical information template;

FIG. 19 is a block diagram of a screen shot of a third portion of an exemplary electronic medical information template;

FIG. 20 is a block diagram of a screen shot of a fourth portion of an exemplary electronic medical information template;

FIG. 21 is a block diagram of a screen shot of a fifth portion of an exemplary electronic medical information template;

FIG. 22 is a block diagram of a screen shot of a sixth portion of an exemplary electronic medical information template; and

FIG. 23 is a block diagram of screen shot illustrating an exemplary first portion of a medical information template on a smart phone.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS Medical Records System

FIG. 1 is a block diagram illustrating an exemplary medical records system 10. The medical records system 10 includes plural medical information templates, including plural paper 12 medical information templates and plural electronic medical information templates 12′, one or more electronic scanners 14 (one illustrated), one or more client computers 16 (one illustrated), one or more client network devices 18, one or more server network devices 20 (one illustrated), and one or more databases 22 (one illustrated). The components of the medical records system 10 communicate via a communications network 24. The one or more different electronic medical information templates 12′ are periodically, automatically and dynamically updated via the communications network 24 to reflect changes in medical, insurance and/or billing practices and/or codes. However, the present invention is not limited to these components, and more, fewer or other components can also be used to practice the invention.

The one or more client network devices 18 include plural software applications 26 (28, 30, 32, 33, etc.) for displaying an electronic medical information template 12′, collecting digital information from the electronic medical information templates 12′, encrypting the collected digital information, for compressing and packaging the encrypted digital information and for securely transmitting the encrypted, compressed and packaged digital information. The one or more client network devices 18 may include the information template reader application 28, a medical code processing engine 30, a medical data presentation application 32, and/or the digital image/data verification application 33, described below. However, the one or more client network devices 18 are not limited to these, and more, fewer or other applications and components can also be used on the one or more client network devices 18.

The client computers 16 include plural software applications 26 for scanning in paper medical information templates 12 from scanner 14 and creating one or more digital images, for encrypting the digital images created, for compressing and packaging the encrypted digital images and for securely transmitting the encrypted, compressed and packaged digital images. The client computers 16 may also include the medical information template reader application 28, a medical code processing engine 30, a medical data presentation application 32, and digital image/data verification application 33 described below. However, the client computers 16 are not limited to these, and more, fewer or other components can also be used on the client computers 16. The client computers 16 may be local or remotely located with respect to the scanner 14.

The client computers 16, client network devices 18 and/or server computers 20 include comprising plural processing applications 26. The plural processing applications 26 include, but are not limited to, a medical information template reader application 28, a medical code processing engine 30, a medical data presentation application 32 and a digital image/data verification application 33.

In one embodiment, applications 26 (28, 30, 32 and 33) are applications for smart phones such as the iPhone by Apple, Inc., Blackberry Storm, by Research In Motion, Inc., Droid by Motorola, Inc., other types of smart phones, other types of mobile and non-mobile phones, etc. However, the present invention is not limited to such applications, and more, fewer or other software applications can also be used on the server computer 20.

In one embodiment of the invention, the plural processing applications are software applications. However, the plural processing applications 26 can also include plural software, firmware, hardware applications and/or combinations thereof and the present invention is not limited to software processing applications. One or more applications (e.g., 30, etc.) on the server computer 20 continuously and dynamically updates electronic medical templates 12′ on the client network devices 18 and the client computers 16. The server computers 20 may be local or remote to the client computers 16 and client network devices 18.

The database 22 comprises a relational database. However, the present invention is not limited to a relational database and other types of databases can also be used.

The communications network 24 includes a wired or wireless communications network including components of the Public Switched Telephone Network (“PSTN”), the Internet, intranets, or types of wired or wireless, including voice and data communications networks, and including local area networks (“LAN”) and wide area networks (“WAN”).

The server computers 20, the client computers 16 and client network devices 18 include wired and wireless interfaces to communicate with the communication network 24. The communications network 24 includes a wire or wireless, telecommunications network and/or a wired and/or wireless data network (e.g., Internet Protocol (IP) suite of protocols including Transmission Control Protocol (TCP), User Datagram Protocol (UDP), etc.).

In one embodiment of the present invention, the wired interfaces corresponding networking protocols for wired connections to the Public Switched Telephone Network (PSTN) or a cable television network (CATV) including HDTV or the Internet that connect the computers and network devices via one or more twisted pairs of copper wires, digital subscriber lines (e.g. DSL, ADSL, VDSL, etc.) coaxial cable, fiber optic cable, other connection media or other connection interfaces. The PSTN is any public switched telephone network provided by AT&T, GTE, Sprint, MCI, SBC, Verizon and others.

In one embodiment, of the invention, the wireless interfaces include WPAN wireless personal area network (WPAN) interfaces. As is known in the art, a WPAN is a personal area network for interconnecting devices centered around an individual person's devices in which the connections are wireless. A WPAN interconnects all the ordinary computing and communicating devices that a person has on their desk (e.g. computer, etc.) or carry with them (e.g., PDA, mobile phone, two-way pager, etc.)

Typically, a wireless personal area network uses some technology that permits communication only within about 10 meters. One such technology is “Bluetooth.” Another such technology is “Zigbee.”

A key concept in WPAN technology is known as “plugging in.” In the ideal scenario, when any two WPAN-equipped devices come into close proximity (within several meters of each other) or within a few kilometers of a central server (not illustrated), they can communicate via wireless communications as if connected by a cable. WPAN devices can also lock out other devices selectively, preventing needless interference or unauthorized access to secure information.

In one embodiment of the present invention, the wireless interfaces include but are not limited to, an IEEE 802.11a, 802.11b, 802.11g, 802.11n, 802.15.4 (ZigBee), 802.16a, 802.16g, “Wireless Fidelity” (Wi-Fi), “Worldwide Interoperability for Microwave Access” (WiMAX), ETSI High Performance Radio Metropolitan Area Network (HIPERMAN) “RF Home,” or other types of wireless interfaces. However, the present invention is not limited to such wireless interface and other types of wireless interfaces can also be used.

In another embodiment of the present invention, the wireless interface includes a wireless sensor device that comprises an integral or separate Bluetooth and/or infra data association (IrDA) module for wireless Bluetooth or wireless infrared communications.

As is known in the art, an 802.11b is a short-range wireless network standard. The IEEE 802.11b standard defines wireless interfaces that provide up to 11 Mbps wireless data transmission to and from wireless devices over short ranges. 802.11a is an extension of the 802.11b and can deliver speeds up to 54M bps. 802.11g deliver speeds on par with 802.11a. However, other 802.11xx interfaces can also be used and the present invention is not limited to the 802.11 protocols defined. The IEEE 802.11a, 802.11b and 802.11g standards are incorporated herein by reference.

As is known in the art, Wi-Fi is a type of 802.11xx interface, whether 802.11b, 802.11a, dual-band, etc. Wi-Fi devices include an RF interfaces such as 2.4 GHz for 802.11b or 802.11g and 5 GHz for 802.11a. More information on Wi-Fi can be found at the URL “www.weca.net.”

As is known in the art, 802.15.4 (Zigbee) is low data rate network standard used for mesh network devices such as sensors, interactive toys, smart badges, remote controls, and home automation. The 802.15.4 standard provides data rates of 250 kbps, 40 kbps, and 20 kbps., two addressing modes; 16-bit short and 64-bit IEEE addressing, support for critical latency devices, such as joysticks, Carrier Sense Multiple Access/Collision Avoidance, (CSMA-CA) channel access, automatic network establishment by a coordinator, fully handshaked protocol for transfer reliability, power management to ensure low power consumption for multi-month to multi-year battery usage and up to 16 channels in the 2.4 GHz ISM band (Worldwide), 10 channels in the 915 MHz (US) and one channel in the 868 MHz band (Europe). The IEEE 802.15.4-2003 standard is incorporated herein by reference. More information on 802.15.4 and ZigBee can be found at the URL “www.ieee802.org” and “www.zigbee.org” respectively.

As is known in the art, WiMAX is an industry trade organization formed by leading communications component and equipment companies to promote and certify compatibility and interoperability of broadband wireless access equipment that conforms to the IEEE 802.16XX and ETSI HIPERMAN. HIPERMAN is the European standard for metropolitan area networks (MAN).

The IEEE The 802.16a and 802.16g standards are wireless MAN technology standard that provides a wireless alternative to cable, DSL and T1/E1 for last mile broadband access. It is also used as complimentary technology to connect IEEE 802.11XX hot spots to the Internet.

The IEEE 802.16a standard for 2-11 GHz is a wireless MAN technology that provides broadband wireless connectivity to fixed, portable and nomadic devices. It provides up to 50-kilometers of service area range, allows users to get broadband connectivity without needing direct line of sight with the base station, and provides total data rates of up to 280 Mbps per base station, which is enough bandwidth to simultaneously support hundreds of businesses with T1/E1-type connectivity and thousands of homes with DSL-type connectivity with a single base station. The IEEE 802.16g provides up to 100 Mbps.

The IEEE 802.16e standard is an extension to the approved IEEE 802.16/16a/16g standard. The purpose of 802.16e is to add limited mobility to the current standard which is designed for fixed operation.

The ESTI HIPERMAN standard is an interoperable broadband fixed wireless access standard for systems operating at radio frequencies between 2 GHz and 11 GHz.

The IEEE 802.16a, 802.16e and 802.16g standards are incorporated herein by reference. More information on WiMAX can be found at the URL “www.wimaxforum.org.” WiMAX can be used to provide a WLP.

The ETSI HIPERMAN standards TR 101 031, TR 101 475, TR 101 493-1 through TR 101 493-3, TR 101 761-1 through TR 101 761-4, TR 101 762, TR 101 763-1 through TR 101 763-3 and TR 101 957 are incorporated herein by reference. More information on ETSI standards can be found at the URL “www.etsi.org.” ETSI HIPERMAN can be used to provide a WLP.

As is known in the art, Bluetooth is a short-range radio frequency technology aimed at simplifying communications among network devices and between network devices. Bluetooth wireless technology supports both short-range point-to-point and point-to-multipoint connections. The Bluetooth Specification, GL 11r02, March 2005, prepared by the Bluetooth SIG, Inc. is incorporated herein by reference.

The medical records system further includes a secure audio dictation interface 27. The audio dictation interface 27 allows a provider to securely access the medical records system 10 (e.g., via a secure web-page, secure dial-in, secure voice-mail, etc.) and dictate audio information via a microphone such as those attached to a computer, mobile phone, personal digital assistant (“PDA”), etc. The dictated audio information is then stored in database 22 as an audio file in an appropriate audio format (e.g., a MIDI, WAVE, MP3, or other audio format). The audio dictation interface 27 also allows a medical transcriptionist to securely access a saved audio file and transcribe the audio information into electronic text. The electronic text is saved in database 22 and is associated with an electronic medical record created for a patient encounter as is explained below.

An operating environment for components of the medical the medical records system 10 include a processing system with one or more high speed Central Processing Unit(s) (“CPU”) and a memory or other computer readable mediums. In accordance with the practices of persons skilled in the art of computer programming, the present invention is described below with reference to acts and symbolic representations of operations or instructions that are performed by the processing system, unless indicated otherwise. Such acts and operations or instructions are referred to as being “computer-executed,” “CPU executed” or “processor executed.”

It will be appreciated that acts and symbolically represented operations or instructions include the manipulation of electrical signals by the CPU. An electrical system represents data bits which cause a resulting transformation or reduction of the electrical signals, and the maintenance of data bits at memory locations in a memory system to thereby reconfigure or otherwise alter the CPU's operation, as well as other processing of signals. The memory locations where data bits are maintained are physical locations that have particular electrical, magnetic, optical, or organic properties corresponding to the data bits.

The data bits may also be maintained on a computer readable medium including magnetic disks, optical disks, organic memory, and any other volatile (e.g., Random Access Memory (“RAM”)) or non-volatile (e.g., Read-Only Memory (“ROM”)) mass storage system readable by the CPU. The computer readable medium includes cooperating or interconnected or distributed computer readable medium, which exist exclusively on the processing system or be distributed among multiple interconnected processing systems that may be local or remote to the processing system and may be accessed by one or more CPUs or processors.

Preferred embodiments of the present invention include computers, servers network devices and interfaces that are compliant with all or part of standards proposed by the Institute of Electrical and Electronic Engineers (“IEEE”), International Telecommunications Union-Telecommunication Standardization Sector (“ITU”), European Telecommunications Standards Institute (ETSI), Internet Engineering Task Force (“IETF”), U.S. National Institute of Security Technology (“NIST”), American National Standard Institute (“ANSI”), Wireless Application Protocol (“WAP”) Forum, Bluetooth Forum, or the ADSL Forum. However, network devices based on other standards could also be used. IEEE standards can be found on the World Wide Web at the Universal Resource Locator (“URL”) “www.ieee.org.” The ITU, (formerly known as the CCITT) standards can be found at the URL “www.itu.ch.” ETSI standards can be found at the URL “www.etsi.org.” IETF standards can be found at the URL “www.ietf.org.” The NIST standards can be found at the URL “www.nist.gov.” The ANSI standards can be found at the URL “www.ansi.org.” Bluetooth Forum documents can be found at the URL “www.bluetooth.com.” WAP Forum documents can be found at the URL “www.wapforum.org.” ADSL Forum documents can be found at the URL “www.adsl.com.”

Medical Information Templates

FIGS. 2A and 2B are a block diagram 34 illustrating an exemplary paper medical information template 12 including a front side 36 (FIG. 2A) and a back side 38 (FIG. 2B). FIGS. 2A-2D and FIGS. 8-12 are copyright © 2002-2003 by Practice Velocity, LLC. All rights reserved.

Exemplary paper medical information template 34 is an exemplary medical information template 34 from the set of plural paper 12 and electronic 12′ medical information templates used, including plural different medical practice templates used for example, in a family practice office, emergency room, urgent care, or walk-in clinic or for any appropriate medical practice. Such a paper or electronic information template 34 is used by providers and other clinical personnel to complete documentation of history, physical exam, complexity of medical decision making, and other relevant information for an encounter with a patient.

The plural medical information templates 12 also include specialized paper medical information templates (not illustrated) such as those used for pediatrics, obstetrics and gynecology, cardiology, neurology, etc. Such specialized paper medical information templates are configured and laid out similar to the exemplary paper medical information template 34 of FIG. 2 and are used to complete documentation for history, physical exam, complexity of medical decision making and other relevant information in a specialized area of medicine (e.g., for a physician with a specialized medical practice).

The plural medical information templates also include general and specialized electronic medical information templates 12′ (FIGS. 17-23) that can be displayed and used on desktop and handheld network devices 18. The electronic medical information templates 12′ can be displayed on desktop electronic devices such as computers, etc. or other types of desktop network devices 18. The electronic medical information templates can also be displayed and used on hand-held electronic devices, such as, personal digital/data assistants (“PDA”), electronic tablets, Internet appliances, mobile phones, smart phones such as the iPhone by Apple, Inc., Blackberry Storm and other models, by Research In Motion, Inc., Droid by Motorola, Inc, other smart phones and mobile phones, etc., electronic gaming platforms (e.g., Play Station Portable (PSP) by Sony, the Gameboy and DS by Nintendo, etc.) or other types of handheld client network devices 18.

Returning to FIG. 2, the paper medical information template 34 is designed such that the plural processing applications 26 may read and/or interpret data from a digital image made of a paper copy of a medical information template 34, or directly from electronic medical information templates 12′ created for an electronic device.

The paper medical information template 34 includes a limited number of check boxes, blanks and diagrams or other pre-denoted fields to fill in. The limited number of choices helps reduce the amount and/or complexity of data to be reviewed and the number of diagnostic options to be considered while at the same time helping ensure the appropriate number and type medical codes will be generated for the patient encounter.

The medical information templates 12, 12′ including exemplary paper medical information template 34, are not used as documents where diagnostic information is entered by a provider or other clinical personnel, where the responsibility for deciphering and selecting the appropriate codes is then performed directly by a physician or transferred to a person with knowledge of medical coding and medical codes (corresponding to various diagnoses, procedures or services), who manually enters the appropriate medical codes into a document or a medical records systems.

Instead, the plural medical information templates 12, 12′ are designed and laid out in a format that systematically documents the specific information, corresponding to medical codes that are a collection of the most common and most likely to encountered for a specific type of general or specialized medical practice. By simply completing the medical information templates 12, 12′ during a patient encounter, the physician (or other skilled medical personnel such as nurses, physician assistants, etc.) will cause many, if not all, of the proper medical coding to be automatically generated when the electronic images of the templates are processed by the medical records system 10.

When they are processed by the medical records system 10, the plural medical information templates 12, 12′ allow automatic generation and display in real-time, of the proper medical and insurance codes typically used by medical and health care providers for general and specific types of medical diagnosis's (e.g., emergency room or walk-in clinic diagnosis, specialized medical practices, etc.). The design and layout of the plural medical information templates 12, 12′ also allows automatic easy and efficient processing by the medical records system 10 and other types of data processing systems such as billing and invoicing systems

The plural medical information templates 12, 12′ may simplify documentation using any of the following methods: (1) reducing the complexity associated with choosing the correct level of medical decision making by allowing only a small number of check boxes (or other easily-denoted fields) for each level of risk; (2) eliminate the use of amount and/or complexity of medical data to be reviewed. Selected data may be eliminated on templates designed for practices where extensive review of such data is very rare. However, check boxes (or other easily-denoted fields) for other data may be placed on templates for medical practices where use of this category is helpful for determining a proper level of CPT E/M coding; (3) limiting and categorizing a number of diagnoses or management options thereby further reducing risk and complexity. Check boxes (or other easily-denoted fields) are used directly for categorizing the number of diagnoses or management options. The check boxes (or other easily-denoted fields) are limited in number to those in each category allowed by current coding guidelines. The provider may check as many as possible, but can not check too many, as the check boxes on the template are limited as noted above; (4) electronically process, display and utilize in real-time patient encounter information recorded on a paper medical template 12 after the paper medical template has been converted into a digital image; (5) help electronically process, display, and utilize in real-time data recorded on electronic medical templates 12′ after the electronic medical information template has been processed; and (6) allow easy changes of coding definitions. If coding definitions are changed by any entity, changes are easily made within the method and system. The one or more different electronic medical templates are continuously and dynamically updated on the client network devices 18 via the communications network 24.

FIG. 2B also includes an exemplary information area 40 with four check-boxes for the Neck as is explained in connection with FIG. 3. In addition, FIG. 2B illustrates an exemplary information area 41 with plural check boxes for completing a medical diagnosis as is explained below in connection with Table 3.

FIG. 3 is a block diagram 42 illustrating portions of the exemplary paper medical information template 34 from FIG. 2B. For example, the exemplary paper medical information template 34 on its back side 38 (FIG. 2B) includes a box labeled “Neck” 40 and a box labeled “Diagnoses” 41.

A Neck box 40 (FIG. 3) includes two columns of check boxes 44, 46 typically identified by colors including for example, green and red. The green check box is the first or leftmost check box and the red check box is the second or rightmost check box. The green check box indicates the provider examined the patient, but the patient does not have any abnormality in the indicated body area or system. The red check box indicates the provider examined the patient, but the patient does have one or more abnormalities in the indicated body area or system. However, the exemplary paper medical information template 34 is not limited to such check boxes and other colors, other designations and other layouts for the check boxes can also be used.

For example, the Neck box 40 includes a first row 48 labeled “Exam (mass, appearance, symmetry, trachea, crepitus)” and a second row 40 labeled “Thyroid (enlargement, tenderness, mass).”

The information in these rows may include some or all of the specified physical exam items from the published guidelines for CPT E/M codes related to the neck. Thus, a physicians (or other skilled medial personnel) with no knowledge or a large amount of knowledge of medical coding practices can use the medical information template efficiently. In both situations, the proper medical codes are generated automatically for the patient encounter. Coding is not based on the coding knowledge of the provider (or other skilled medical personnel), but rather on the actual documentation of the encounter on the patient's medical record.

During an examination of the patient, the provider might check the patient's neck if the patient was in an automobile accident or otherwise complained of neck pain. If the patient's neck exam was normal, the physical would check the green check box column 44 of the first row 48 in the Neck box 38. (See FIG. 2D).

If the patient's neck exam was abnormal, the provider would check the red check box column 46 of the first row 48 in the Neck box 40.

The provider need not specify and document the actual abnormality using handwritten, typed text, voice dictation, or choose from a list of specific abnormal conditions. A similar procedure would be followed during the examination of the patient's Thyroid in the second row 50 of the Neck box 40.

Diagnoses box 41 includes check boxes for new and established diagnoses. It also includes a range of possible levels of medical diagnoses from minor to complex as is explained below.

The plural medical information templates 12, including exemplary paper medical information template 34, are scanned into the medical records system 10 via scanner 14. Patient encounter information is collected from the plural electronic medical information templates 12′ via a number of other methods via a communications connection established with the server computers 20 via the communications network 24 (e.g., infrared connection, or other wired or wireless connection via a Personal Digital Assistant (“PDA”), mobile phone, etc.).

The data on the plural medical information templates 12, 12′ is used for multiple purposes including (but not limited to) those purpose illustrated in Table 1a. However, the present invention is not limited to the purposes limited in Table 1a and more, fewer or other purposes can also be used to practice the invention.

TABLE 1a 1. Coding of and/or billing for Evaluation and Management codes (“E/Ms”) codes in real-time. 2. Coding of and/or billing for Current Procedural Terminology (“CPTs”) codes in real-time. 3. Coding of and/or billing for Health Care Financing Administration Common Procedural Coding System (“HCPCS”) codes in real-time. 4. Coding of and/or billing for International Classification of Diseases (“ICD-9”) 9^(th) or 10^(th) (“ICD-10”) Edition Clinical Modification codes in real-time. 5. Coding of modifiers to be attached to the above-generated codes. 6. Coding of and/or billing for other codes for medical services as defined by governmental agencies, medical associations, insurance companies, other payers, or any other entity that creates or defines codes or a system of codes for the purposes of documenting and/or billing medical services or supplies in real-time. 7. Production of a paper or electronic invoice in real-time immediately after a patient encounter using one or more of the medical codes described in 1-5. 8. Production an electronic medical record in real-time immediately after a patient encounter using or more of the medical codes described in 1-5. 9. Production of other plural electronic templates used to display patient encounter information in real-time. 10. Evaluating the medical data for regulatory compliance (e.g., HIPAA, etc.) 11. Evaluating appropriateness of medical care. 12. Production of text documents through electronic conversion of data on the paper medical record into an electronic medical record. 13. Evaluating patterns of physician practices. 14. Gathering data for medical research. 15. Utilizing generated medical codes in other data processing systems such as other billing and invoicing systems. 16. Other applications deemed appropriate for use of this data while protecting its privacy. Data Flow in the Medical Records System

FIG. 4 is a block diagram illustrating an exemplary data flow 52 for the medical records system 10 for a paper medical information template 12. The data flow 52 includes scanning a paper medical information template 12 (e.g., paper medical information template 34 of FIGS. 2A and 2B) into one or more digital images 54 with a pre-determined image format such as a Tagged Image Format (“TIF”) or other types of digital image formats (e.g., Bit Map (“BMP”), Graphics Interchange Format (“GIF”), Joint Pictures Expert Group (“JPEG”), etc.) known in the art, with scanner 14. The paper medical record may also be scanned into other digital formats (e.g., other types of digital data) and the invention is not limited to scan the paper medical information template into a digital image.

The digital images are encrypted 56 to ensure the data it includes is protected and kept private. For example, the digital images may be encrypted using RSA encryption, Data Encryption Standard (“DES”) encryption, Advanced Encryption Standard (“AES”) encryption, or other encryption methods known in the art.

Devices and interfaces of the present invention include various types of security and encryption. Wireless Encryption Protocol (“WEP”) (also called “Wired Equivalent Privacy”) is a security protocol for WiLANs defined in the IEEE 802.11b standard. WEP is cryptographic privacy algorithm, based on the Rivest Cipher 4 (RC4) encryption engine, used to provide confidentiality for 802.11b wireless data.

As is known in the art, RC4 is cipher designed by RSA Data Security, Inc. of Bedford, Mass., which can accept encryption keys of arbitrary length, and is essentially a pseudo random number generator with an output of the generator being XORed with a data stream to produce encrypted data.

One problem with WEP is that it is used at the two lowest layers of the OSI model, the physical layer and the data link layer, therefore, it does not offer end-to-end security. One another problem with WEP is that its encryption keys are static rather than dynamic. To update WEP encryption keys, an individual has to manually update a WEP key. WEP also typically uses 40-bit static keys for encryption and thus provides “weak encryption,” making a WEP device a target of hackers.

The IEEE 802.11 Working Group is working on a security upgrade for the 802.11 standard called “802.11i.” This supplemental draft standard is intended to improve WiLAN security. It describes the encrypted transmission of data between systems 802.11x WiLANs. It also defines new encryption key protocols including the Temporal Key Integrity Protocol (TKIP). The IEEE 802.11i draft standard, version 4, completed Jun. 6, 2003, is incorporated herein by reference.

The 802.11i is based on 802.1x port-based authentication for user and device authentication. The 802.11i standard includes two main developments: Wi-Fi Protected Access (“WPA”) and Robust Security Network (“RSN”).

WPA uses the same RC4 underlying encryption algorithm as WEP. However, WPA uses TKIP to improve security of keys used with WEP. WPA keys are derived and rotated more often than WEP keys and thus provide additional security. WPA also adds a message-integrity-check function to prevent packet forgeries.

RSN uses dynamic negotiation of authentication and selectable encryption algorithms between wireless access points and wireless devices. The authentication schemes proposed in the draft standard include Extensible Authentication Protocol (“EAP”). One proposed encryption algorithm is an Advanced Encryption Standard (“AES”) encryption algorithm.

Dynamic negotiation of authentication and encryption algorithms lets RSN evolve with the state of the art in security, adding algorithms to address new threats and continuing to provide the security necessary to protect information that WiLANs carry.

The NIST developed a new encryption standard, the Advanced Encryption Standard (“AES”) to keep government information secure. AES is intended to be a stronger, more efficient successor to Triple Data Encryption Standard (“3DES”). More information on NIST AES can be found at the URL “www.nist.gov/aes.”

As is known in the art, DES is a popular symmetric-key encryption method developed in 1975 and standardized by ANSI in 1981 as ANSI X.3.92, the contents of which are incorporated herein by reference. As is known in the art, 3DES is the encrypt-decrypt-encrypt (“EDE”) mode of the DES cipher algorithm. 3DES is defined in the ANSI standard, ANSI X9.52-1998, the contents of which are incorporated herein by reference. DES modes of operation are used in conjunction with the NIST Federal Information Processing Standard (“FIPS”) for data encryption (FIPS 46-3, October 1999), the contents of which are incorporated herein by reference.

The NIST approved a FIPS for the AES, FIPS-197. This standard specified “Rijndael” encryption as a FIPS-approved symmetric encryption algorithm that may be used by U.S. Government organizations (and others) to protect sensitive information. The NIST FIPS-197 standard (AES FIPS PUB 197, November 2001) is incorporated herein by reference.

The NIST approved a FIPS for U.S. Federal Government requirements for information technology products for sensitive but unclassified (“SBU”) communications. The NIST FIPS Security Requirements for Cryptographic Modules (FIPS PUB 140-2, May 2001) is incorporated herein by reference.

As is known in the art, RSA is a public key encryption system which can be used both for encrypting messages and making digital signatures. The letters RSA stand for the names of the inventors: Rivest, Shamir and Adleman. For more information on RSA, see U.S. Pat. No. 4,405,829, now expired, incorporated herein by reference.

As is known in the art, “hashing” is the transformation of a string of characters into a usually shorter fixed-length value or key that represents the original string. Hashing is used to index and retrieve items in a database because it is faster to find the item using the shorter hashed key than to find it using the original value. It is also used in many encryption algorithms.

Secure Hash Algorithm (SHA), is used for computing a secure condensed representation of a data message or a data file. When a message of any length<2⁶⁴ bits is input, the SHA-1 produces a 160-bit output called a “message digest.” The message digest can then be input to other security techniques such as encryption, a Digital Signature Algorithm (DSA) and others which generates or verifies a security mechanism for the message. SHA-512 outputs a 512-bit message digest. The Secure Hash Standard, FIPS PUB 180-1, Apr. 17, 1995, is incorporated herein by reference.

Message Digest-5 (MD-5) takes as input a message of arbitrary length and produces as output a 128-bit “message digest” of the input. The MD5 algorithm is intended for digital signature applications, where a large file must be “compressed” in a secure manner before being encrypted with a private (secret) key under a public-key cryptosystem such as RSA. The IETF RFC-1321, entitled “The MD5 Message-Digest Algorithm” is incorporated here by reference.

As is known in the art, providing a way to check the integrity of information transmitted over or stored in an unreliable medium such as a wireless network is a prime necessity in the world of open computing and communications. Mechanisms that provide such integrity check based on a secret key are called “message authentication codes” (MAC). Typically, message authentication codes are used between two parties that share a secret key in order to validate information transmitted between these parties.

Keyed Hashing for Message Authentication Codes (HMAC), is a mechanism for message authentication using cryptographic hash functions. HMAC is used with any iterative cryptographic hash function, e.g., MD5, SHA-1, SHA-512, etc. in combination with a secret shared key. The cryptographic strength of HMAC depends on the properties of the underlying hash function. The IETF RFC-2101, entitled “HMAC: Keyed-Hashing for Message Authentication” is incorporated here by reference.

As is known in the art, an Electronic Code Book (ECB) is a mode of operation for a “block cipher,” with the characteristic that each possible block of plaintext has a defined corresponding cipher text value and vice versa. In other words, the same plaintext value will always result in the same cipher text value. Electronic Code Book is used when a volume of plaintext is separated into several blocks of data, each of which is then encrypted independently of other blocks. The Electronic Code Book has the ability to support a separate encryption key for each block type.

As is known in the art, Diffie and Hellman (DH) describe several different group methods for two parties to agree upon a shared secret in such a way that the secret will be unavailable to eavesdroppers. This secret is then converted into various types of cryptographic keys. A large number of the variants of the DH method exist including ANSI X9.42. The IETF RFC-2631, entitled “Diffie-Hellman Key Agreement Method” is incorporated here by reference.

However, the present invention is not limited to the security or encryption techniques described and other security or encryption techniques can also be used.

As is known in the art, IP is an addressing protocol designed to route traffic within a network or between networks. For more information on IP 54 see IETF RFC-791 incorporated herein by reference.

TCP provides a connection-oriented, end-to-end reliable protocol designed to fit into a layered hierarchy of protocols that support multi-network applications. For more information on TCP 58 see RFC-793, incorporated herein by reference.

UDP provides a connectionless mode of communications with datagrams in an interconnected set of networks. For more information on UDP see ITEF RFC-768 incorporated herein by reference.

As is known in the art, the HyperText Transport Protocol (HTTP) Secure (HTTPs), is a standard for encrypted communications on the World Wide Web. HTTPs is actually just HTTP over a Secure Sockets Layer (SSL). For more information on HTTP, see IETF RFC-2616 incorporated herein by reference.

As is known in the art, the SSL protocol is a protocol layer which may be placed between a reliable connection-oriented network layer protocol (e.g. TCP/IP) and the application protocol layer (e.g. HTTP). SSL provides for secure communication between a source and destination by allowing mutual authentication, the use of digital signatures for integrity, and encryption for privacy.

The SSL protocol is designed to support a range of choices for specific security methods used for cryptography, message digests, and digital signatures. The security method(s) are negotiated between the source and designation at the start of establishing a protocol session. The SSL 2.0 protocol specification, by Kipp E. B. Hickman, 1995 is incorporated herein by reference. More information on SSL is available at the URL See “netscape.com/eng/security/SSL_(—)2.html.”

As is known in the art, Transport Layer Security (TLS) provides communications privacy over the Internet. The protocol allows client/server applications to communicate over a transport layer (e.g., TCP) in a way that is designed to prevent eavesdropping, tampering, or message forgery. For more information on TLS see IETF RFC-2246, incorporated herein by reference.

The encrypted digital images are compressed and packaged 58 to reduce their size and speed up transmission over the communications network 24. For example, the encrypted digital images may be compressed and packaged using PKZIP, by Pkware, Inc. of Brown Deere, Wis., WINZIP, by Microsoft, Inc. of Redmond, Wash., or other types of data compression and data packaging methods known in the art.

The compressed encrypted digital images are securely transmitted 60 over the communications network 24 to the server computer 20. For example, compressed encrypted digital images are securely transmitted via a Secure Sockets Layer (“SSL”) (e.g., using an encryption key of 1000-bits or more to protect privacy of the digital images), using the File Transfer Protocol (“FTP”).

As is known in the art, a “secure transmission” over a communications network includes a transmission over a communications connection that is protected against unauthorized access, operation, or use, by means of encryption, or other forms of control or security.

However, other secure transmission techniques (e.g., RSA, DES, AES, data encryption, Internet Protocol Security (“IPsec”), etc.) and other data protocols (e.g., Transmission Control Protocol (“TCP”)/Internet Protocol (“IP”), User Datagram Protocol (“UDP”), etc.) known in the art can also be used.

The server computer 20 securely receives the compressed encrypted digital images and un-compresses 62 encrypted digital images back to their original size. The server computer 20 decrypts 64 the un-compressed digital images to obtain the original digital images 54 scanned into the medical records processing system 10.

The original digital images 54 are processed 66 by the plural processing applications 26. For example, the medical template reader application 28 extracts patient encounter information from the original digital images 54 and creates a number of internal data structures used to verify and store the patent encounter information as is described below.

In one embodiment of the invention, if the medical template reader application 28 determines that it can not accurately determine specific patient encounter information from the original digital images 54 (e.g., can not electronically scan and process the s or other medical personnel's handwriting, marks on check boxes overlap, etc.), the patient encounter information in question is electronically highlighted on the original digital images 54 and displayed 68 in real-time by the medical data presentation application 32 for a human user to interpret and/or verify 70.

This real-time verification application 33 allows errors and/or inconsistencies in electronic interpretation of the data on the digital images 54 from the scanned paper templates 12 or original electronic data entered into an electronic template 12′ to be immediately corrected by a human user. If the digital image is missing necessary, important, required or relevant data (e.g., provider signature, vital signs, patient demographics, etc) this information may be returned to the provider so that the provider appropriately completes this data and the paper template is rescanned.

As is known in the art, “real-time” operations are those in which a computer's systems activities match a human perception of a time period or are computer system operations that proceed at rate similar to an external physical process. In another embodiment of the invention, near real-time or non-real-time processing can also be used. In one embodiment of the invention, real-time operations are conducted in a time-period of a few milli-seconds or faster in length.

In another embodiment of invention, if the medical template reader application 28 can not properly determine patient encounter information from the original digital images 54, a determination as a “best guess” is made for the patient encounter information in question using one or more internal (e.g., software 33, hardware, firmware, etc.) digital image analysis techniques available to the medical template reader application 28. This embodiment does not necessarily rely on verification by a human user.

If the medical template reader application 28 has determined patient encounter information from the original digital images 54, and this has been verified and/or corrected by a human user the medical code processing engine 30 automatically generates the appropriate medical codes (e.g., E/M, CPT, HCPCS, etc.) in real-time for the patient encounter information using the internal data structures of stored patient encounter information. The generated medical codes along with the original digital images 54 including the patient encounter information, other patient encounter information extracted and other patient encounter information newly generated (e.g., a new electronic medical information record, an electronic invoice, etc.) are stored 72 in the database 22.

In one embodiment of the invention, the generated medical codes, generated tables of patient encounter information and the original digital images 54 are stored 72 indatabases 22, wherein databases 22 are relational databases. The generated medical codes and the original digital images 50 are stored in an open database connectivity (“ODBC”) format using structure query language (“SQL”) commands to access the databases 22.

However, the invention is not limited to such an embodiment and other types of databases (e.g., non-relational), database formats and database commands can also be used with the databases 22.

As is known in the art, ODBC is standard database access method developed by Microsoft Corporation. ODBC makes it possible to access any data from any application, regardless of which database management system (“DBMS”) is handling the data. As is known in the art, SQL is database sublanguage used in querying, updating, and managing relational databases.

The generated medical codes are also used by the medical code processing engine 30 to create an electronic or paper invoice and a summary of the collected medical information for the patient in the form of an electronic medical record in real-time or sent to another data processing system for additional processing The electronic codes and electronic medical record is securely transmitted 74 (e.g., using SSL as described above) and is displayed 76 by the medical data presentation application 32 in real-time for medical office personal. Delayed processing may also be performed as appropriate to the specific situation (e.g., by another data processing system such as an external billing or invoicing system)

The electronic invoice and electronic medical record can be displayed 76 in real-time via the medical data presentation application 32 on the client computers 16 (not illustrated), the server computer 20 (not illustrated), on another secure display 77 in the medical facility that collected medical information form the patient, or by any other authorized user on a computer (not illustrated) equipped for this display.

For example, if a patient entered a clinic and desired to pay by credit card or cash, immediately after being examined by a provider, the patient encounter information recorded on a paper medical information template 12 (e.g., FIG. 2) would be scanned in and processed as just described for FIG. 4. As the patient received his/her exit instructions (e.g., receiving instructions for prescribed medications, instructions to further threat an injury or illness at home, etc.) the medical codes generated in real-time are used to create an electronic invoice in real-time for the patient with an appropriate fee for the patient visit. Thus, the patient can be charged the appropriate fee immediately as he/she is ready to leave the clinic without delaying the patient any significant amount of time. This leads to greater overall patient satisfaction at a time when the patient is in pain or is not otherwise feeling well. This also leads to correct and immediate revenue for the medical facility and/or physician.

The electronic invoice and electronic medical record can also be securely transmitted 74 and displayed 76 at a later time (i.e., non real-time) for medical office personal for patients who are covered by insurance and for physicians who review the patient's chart at a later time.

FIG. 5 is a block diagram illustrating an exemplary data flow 78 for the medical records system of FIG. 1 for an electronic medical information template 12′. Electronic medical information templates 12′ are processed in a manner similar to the paper medical information templates 12 described above. In this embodiment, patient encounter information is not recorded on paper medical information templates. Instead, it is recorded electronically directly on the electronic medical information templates 12′.

In one embodiment, the electronic medical information template 12′ is displayed on a computer screen or handheld network devices 18. Digital information 80 from the electronic medical information template 12′ is collected and encrypted 82 on the electronic device to ensure the data is protected and kept private.

The encrypted digital information is compressed 84 on the network devices 18 to reduce its size and speed up transmission over the communications network 24. The compressed encrypted digital information is securely transmitted 86 from the network devices 18 over the communications network 24 to the server computer 20.

The server computer 20 securely receives the compressed encrypted digital information and un-compresses 88 encrypted digital information back to its original size. The server computer 20 decrypts 90 the un-compressed digital information to obtain the original digital information 80 collected electronically from the network devices 18,

The original digital information 80 is processed 92 by the processing applications 26. The medical template reader application 28 extracts patient encounter information from the original digital information 80 and creates a number of internal data structures used to store the patent information.

In this data flow, the verification steps described above for the paper electronic information templates 12′ are typically not necessary because there are no digital images to process, only original digital information 80 generated directly from the electronic medical information template. However, automated internal or human verification may also be performed. In addition, the verification application 33 may be used to check and verify either all information input into the electronic medical information templates 12′ or selected ones of the input information.

For example, if the medical information entered into the medical information template 12′ was for a male patient, and questions about pregnancy or menstrual periods were included in the information collected, the verification application 33 would automatically flag such inconsistencies for review. The verification application 33 is also used to flag inconsistencies between chief complaints and known interactions between one or more medications that the patient may be currently taking and/or new medications prescribed for the current patient encounter.

The medical code processing engine 30 automatically generates the appropriate medical codes (e.g., E/M, CPT, HCPCS, etc.) for the patient encounter information using the tables of patient encounter information. The generated medical codes are stored 94 along with the original digital information 80 including the patient encounter information in the database 22.

The generated medical codes are used by the medical code processing engine 30 to create an electronic invoice (Table 7) and an electronic medical record (FIG. 22) for the patient. The electronic invoice and electronic medical record is securely transmitted 96 (e.g., using SSL as described above) and is displayed 98 by the medical data presentation application 32 in real-time for medical office personal.

The electronic invoice (Table 7) and electronic medical record (FIG. 22) are displayed 98 in real-time via the medical data presentation application 32 on the client network device 18, the server computer 20 (not illustrated), on another secure display 99 in the medical facility that collected medical information form the patient via the medical data presentation application 32 or on the client network devices 18 from which the patient encounter information was collected (not illustrated).

The electronic invoice (Table 7) and electronic medical record (FIG. 22) can also be securely transmitted 96 and displayed 98 at a later time (i.e., in non real-time) for medical office personal for patients who are covered by insurance and for physicians who review the patient's chart at a later time. Billing codes can also be electronically downloaded to other software applications for further processing, storage or transmission to other entities or other data processing systems.

In another embodiment, all the processing just described for the dataflow in FIG. 5 is completed on the client network devices 18 (e.g., Method 184, etc.). In such an embodiment, the client network devices 18 periodically are in secure communications with the server computer 20 at a later time via the communications network 24 to securely transmit a copy of all information collected and created for the patient encounter. In such an embodiment, the client network device 18 securely transmits the original and processed data to a display device in the medical facility for real-time display 99. The real-time display includes the electronic medical record (FIG. 22) as well as the electronic invoice (Table 7).

Processing Medical Information Templates

FIG. 6 is a flow diagram illustrating a Method 100 of processing medical information templates via the medical records system 10. At Step 102, one or more digital images created from a paper medical information template 12 are securely received on a server computer 20 via a communications network 24. The digital images of the medical information template were created by scanning a paper copy of the medical information template 12 into the medical records system 10 via the scanner 14. At Step 104, the one or more digital images are automatically processed on the server computer 20 to extract patient encounter information. At Step 106, one or more medical codes are automatically generated from the extracted patient encounter information. The one or more medical codes generated include, but are not limited to, one or more of E/M, CPT, HCPCS, ICD-9, ICD-10 or other types of codes. At Step 108, the one or more generated medical codes are generated from the extracted patient encounter information are utilized on one or more electronic templates. The one or more electronic templates are displayed on a graphical user interface (GUI) or the one or more electronic templates are used to produce additional medical information documents.

The one or more electronic templates can be displayed on a GUI in real-time directly after a patient encounter providing immediate access to the one or more electronic medical information templates created from the one or more generated medical codes.

The one or more generated medical codes can also be utilized via the one or more electronic templates to produce additional medical information documents, such as invoices, medical records, etc. The additional medical information documents can be produced via exemplary medical records system 10 or be sent to other data processing systems (not illustrated) for further processing. For example, the one or more electronic templates including the one or more generated medical codes (e.g., as XML or other types of electronic templates) can be sent electronically to another data processing system, such as a 3^(rd) party or external medical billing system, that creates and sends an invoice to the patient after the patient encounter.

In such an embodiment, the one or more electronic templates may never be viewed or displayed, but treated as data that is processed automatically by other data processing systems. In such an embodiment, Method 100 is used to create electronic data that is used as an interface to other data processing systems.

The one or more electronic templates include, but are not limited to, an electronic invoice template, an electronic medical record template, a current compliant template, a nurse template, a review template, a diagnosis template; a provider template; and other types of electronic templates.

Chief Complaint Determines Selection of Specific History Template(s):

The chief complaint template describes an organization of an electronic medical record in such a way that medical information provided by personnel (including but not limited to the provider, nursing staff or even the patient himself or herself), can be documented using other electronic templates (e.g., a history template) or another paper template. For example, when a provider/or patient selects chief complaint, an additional electronic template (e.g., a history template) specific to that complaint is generated based on the chief complaint of the patient. This additional electronic template (specific to a given chief complaint) includes information that a medical provider generally documents or could generally be expected to document for a given chief complaint. This information may include, but is not limited to appropriate history of present illness (“HPI”), review of systems (“ROS”), past medical family social history (“PMSFH”), allergies, medications, vital signs, etc. This information may or may not be modified by or for the medical facility that collected the patient encounter information (e.g., via a review template).

Diagnosis determines selection of specific physical exam, treatment and disposition template(s): In addition, the organization of an electronic medical record can be presented in such a way that a paper or an electronic template for a health-care provider for the majority of patients can be documented using another single electronic template (e.g., provider template). When a provider selects a diagnosis for a given patient, a specific electronic template is generated based on that diagnosis of patient (e.g., a diagnosis template). This specific electronic template (i.e., specific to the given diagnosis) includes information that the provider generally documents or could be expected to document for a given diagnosis. This information may include but not be limited to physical exam, treatments (including but not limited to medications, clinical procedures, dressings, splints, casts, crutches, changes in activity, or any other treatment), laboratory testing, diagnostic testing, referrals, consults, disposition, or any other items deemed relevant for the provider's documentation of this chart. A default set of the above data may or may not be set in advance, but can be modified by the provider. This information may or may not be modified by or for the medical facility that collected the patient encounter information (e.g., via a physician review template).

Method 100 may also further comprise generating an electronic invoice in real-time using the one or more medical codes calculated from the extracted patient encounter information. The electronic invoice includes a fee for the medical services provided during the patient encounter. The electronic invoice is presented in real-time via a graphical user interface (“GUI”) (not illustrated in FIG. 6) or utilized in real-time via other data processing systems as was described above

Method 100 may also further comprise generating an electronic medical record in real-time using the one or more medical codes calculated from the extracted patient encounter information and other information extracted from the patient encounter information. The electronic medical record is presented in real-time via a graphical user interface (“GUI”) (not illustrated in FIG. 6) or utilized in real-time via other data processing systems as was described above.

The patient encounter information is extracted by processing the plural check-boxes or other electronically interpreted data and is stored in internal data structures with plural fields on the server computer 20. After Step 104, the internal data structure fields include an indication of which check-boxes and data fields were used (i.e., checked or filled out), and portions of the digital images corresponding to the original paper medical information template 12 may be placed into defined locations on a newly generated electronic invoice template, electronic medical record template, or other electronic template (e.g., nurse, insurance, etc.). The internal data structure fields also include links to the original digital images 54.

These internal data structure fields are also be used for (but are not limited to): (1) storing transcription of handwritten data (using handwriting recognition software, firmware or hardware) to replace the graphic image of handwritten data with transcribed text in the electronic medical record; (2) storing handwritten diagrams that are placed into an electronic template of an electronic medical record; (3) storing computerized text including generated medical codes, computerized text generated from check boxes and other information extracted from the patient encounter information that is displayed at various locations in one or more electronic templates such as the electronic invoice electronic medical record, etc.; (4) storing transcriptions of audio dictation data with transcribed text included in the electronic medical record via audio dictation interface 27.

For example, when the paper medical information template 12 is used to document a patient encounter, a provider can mark the encounter as needing dictation. The electronic medical record created is marked with a status of “dictation pending.” The electronic medical record generated is pre-populated for the pending dictation text including information from the patient encounter. When the provider has time, he/she securely logs into the audio dictation interface 27 (e.g., via a secure web-site) on the medical records system 10 views a queue of patient charts awaiting dictation. A dictation voice file is captured from the provider via the dictation interface and is directly associated with the electronic medical record. In on embodiment, a medical transcriptionist later securely logs onto the same dictation interface, listens to the dictation file and generates an electronic transcript from the dictation. The medical record is populated with electronic information from the electronic transcript. Thus, the electronic medical records can also be dynamically populated with provider dictation text based on the result of the patient encounter. In another embodiment, voice recognition software is used to automatically transcribe the dictation into electronic text.

One set of patient encounter information extracted from the one or more digital images of the paper medical information template 12 at Step 104 (and Step 114 described below) includes extracting historical information (“HX”) obtained from the patient encounter and populating internal data structures. In one embodiment of the invention, extracted historical information is compared against predetermined values for an HX matrix (described below) for determining a historical value used to calculate a medical code. However, the invention is not limited to this embodiment and the extracted historical information can be used with other internal data structures to generate a medical code. In one embodiment, the HX matrix data structure is stored as data bits in a computer readable medium on the client network device 18.

The HX information includes, but is not limited to, predefined elements that make up chief complaint (“CC”) information, history of present illness (“HPI”) information, past medical, family, social history information (“PFMSH”) and review of system (“ROS”) information.

Table 1b illustrates exemplary HX information collected. However, the present invention is not limited to this HX information, more, less and other types of HX information can also be collected from the patient encounter information.

TABLE 1b HX Information Chief Complaint (CC): Description of one or more problems (e.g., sore throat, chest pains, trouble breathing, etc.) History of Present Illness (HPI): Location; quality; severity; duration; timing; context; modifying factors; associated signs and symptoms. Past medical, family, social history (PFMSH): Medical History - the patient's past experiences with illnesses, operations, injuries and treatments. Family History - a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk. Social History - an age appropriate review of past and current activities. Review of Systems (ROS): Constitutional; eyes, ears, nose, mouth, throat; cardio-vascular; respiratory; GI; GU; muscular; neurological; psychological; immune; etc.

Another set of patient encounter information extracted from the digital images of the paper medical information at Step 104 and 114 includes extracting physical examination information (“PX”) obtained from the patient encounter and populating internal data structures. In one embodiment of the invention, extracted physical examination information is compared against predetermined values for a PX matrix (described below) for determining a physical examination value used to calculate a medical code. However, the invention is not limited to this embodiment and the extracted physical examination information can be used with other internal data structures generate a medical code. In one embodiment, the PX matrix data structure is stored as data bits in a computer readable medium on the client network device 18.

Table 2 illustrates where body areas and organ systems from which PX information is collected. However, the present invention is not limited to this PX information, more, less and other types of PX information can also be collected from the patient encounter information.

TABLE 2 PX Areas Body Areas: Head, including face; Back including spine; Chest including breasts; Genitalia including groin and buttocks; Abdomen; Neck; Extremities; etc. Organ Systems: Constitutional; eyes, ears, nose, mouth, throat; cardio-vascular; respiratory; GI; GU; muscular; neurological; psychological; immune; etc.

Table 3 illustrates possible levels of the physical exam types of PX information determined. This example uses one specific set of guidelines commonly referred to and published by the Centers for Medicare & Medicaid Services (“CMS”) as the 1997 Documentation Guidelines for Evaluation and Management Services, but can utilize other methods or guidelines as determined by the type of exam or by changes in prescribed or allowable guidelines. In addition, the PX information is exemplary only, and the present invention is not limited to such PX information.

The PX information is determined in part from processing the check-boxes completed in the medical diagnosis box 41 illustrated in FIG. 2B on the paper medical information template 12 and in FIG. 3.

TABLE 3 PX Types PF One to five elements identified by a bullet (e.g., one to five body areas or organs) EXPF At least six elements identified by a bullet (e.g., up to a total of six organ systems) DET At least twelve items identified by a bullet from 2 (or more) PX areas COMP Two or more elements identified by a bullet in nine or more organ systems.

The PX types include, but are not limited to: a problem focused (“PF”) exam that includes 1-5 specific exam elements identified by a bullet on the paper medical information template 12; an expanded problem focused exam (“EXPF”) that includes at least 6 specific exam elements; identified by a bullet, Detailed exam (“DET”) that includes at least 12 elements in two or more areas/systems, identified by a bullet; and a comprehensive exam (“COMP”) that includes documentation of at least two elements from each of nine areas/systems identified by a bullet.

Another set of patient encounter information extracted from the digital image of the paper medical information at Steps 104 and 114 includes extracting complexity of medical decision making information (“CX”) obtained from the patient encounter and populating internal data structures. In one embodiment of the invention, extracted complexity information is compared against predetermined values for a CX matrix (described below) for determining a complexity value used to calculate a medical code. In one embodiment, the CX matrix data structure is stored as data bits in a computer readable medium on the client network device 18. However, the invention is not limited to this embodiment and the extracted complexity information can be used with other internal data structures generate a medical code. The CX information includes a number of diagnosis (“DX”) or treatment options and risk (“RISK”) information.

Table 3a illustrates exemplary CX information (e.g., FIG. 10). However, the present invention is not limited to this embodiment and other embodiments can also be used to practice the invention.

TABLE 3a CX Types DX RISK straight forward (“SF”) straight forward risk (“SF”), number of diagnosis, <= one includes a self-limited or (code 1). minor problem (code 1). low number of diagnoses low risk (“LOW”), includes (“LOW”), minimal (code 2). two or more minor problems, one stable chronic illness or an acute uncomplicated illness or injury (code 2). moderate number of diagnoses moderate (“MOD”) (“MOD”), multiple (code 3). includes one or more chronic illnesses with mild exacerbation, progression, or side effect treatment, two or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis or an acute illness with systemic symptoms or an acute complicated injury (code 3). high number of possible high risk (“HIGH”), diagnoses (“HIGH”), extensive includes one or more (code 4). chronic illnesses with severe exacerbation, progression or side effects of treatment, or acute or chronic illnesses or injuries that may pose a threat to life or bodily function or an abrupt change in neurological status (code 4).

The DX information includes, but is not limited to: straight forward (“SF”) diagnosis; a low number of diagnoses (“LOW”); a moderate number of diagnoses (“MOD”); and a high number of possible diagnoses (“HIGH”). This DX scoring can be performed using an objective scoring system. A unique aspect of this invention includes (but is not limited to) presentation of these choices in check-box form with each of a maximum number of choices in each category represented by a check-box. Scoring of the DX section can then be performed by adding a point value of each box to obtain the total score in the DX section. Although, scoring of the DX section is not limited to this method, if it is used the following scores correlate with the various levels of DX: (≦1) minimal; (2) limited; (3) multiple; or (4) extensive.

The RISK information includes: minimal or straight forward (“SF”) risk in which the medical problem is self-limited or a minor problem (e.g., cold, insect bite, etc.); low risk (“LOW”) in which the medical problem includes two or more minor problems, one stable chronic illness (e.g., well controlled hypertension or non-insulin dependent diabetes, cataract, etc.) or an acute uncomplicated illness or injury (allergic reaction, simple sprain); moderate risk (“MOD”) in which the medical problem includes one or more chronic illnesses with mild exacerbation, progression, or side effect treatment, two or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis (e.g., lump in breast or prostrate, etc.) an acute illness with systemic symptoms (e.g., pneumonitis, colitis, etc.) or an acute complicated injury (e.g., head injury with brief loss of consciousness); and high risk (“HIGH”) in which the medical problem includes one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, acute renal failure, etc.) or an abrupt change in neurological status (e.g., seizure, TIA, weakness or sensory loss, etc.).

In one embodiment of the invention, omission of analysis of an amount and/or complexity of data reviewed is completed Omission of this aspect of a CX matrix can alter a CX score of very few patient encounters, if the previously used scoring for DX and RISK are utilized. Scoring of an amount and/or complexity of data reviewed may be added to the medical records processing system 10 if indicated by physician utilization, patient population, or changes in coding guidelines.

Another set of patient encounter information extracted from the digital image of the paper medical information at Steps 104 and 114 includes extracting patient status information and patient demographic information. The patient status information includes, but is not limited to, new patient, existing patient, consult, pre-surgery, hospital, etc. The patient demographic information, includes, but is not limited to, patient date-of-birth, etc.

The patient status information and patient demographic information is used in certain situations to override or modify the one or more medical code automatically generated at Steps 106 (and Step 118 described below) and/or to generate additional medical codes. For example, the patient status information, such as admit to the hospital can automatically override or generate addition types of medical codes. As another example, the patient demographic information such as date-of-birth within a certain predetermined range (e.g. very young or very old) can automatically override or generates other types of medical codes.

Another set of patient encounter information extracted from the digital image of the paper medical information at Steps 104 and 114 includes extracting medical diagnosis information for the problems described during the patient encounter.

Another set of patient encounter information extracted from the digital image of the paper medical information at Steps 104 and 114 includes extracting clinical procedure information, treatment information and supply information. The clinical procedure information, includes, but is not limited to, clinical or hospital or surgical procedure information, such as stitches, applying cast, a desired operation, diagnostic tests (e.g., x-rays, MRI scans, CRT scans, etc.) and other types of clinical procedure information. The treatment information, includes, but is not limited to, medications, physical therapy, etc. The supply information includes, but is not limited to, types of medical supplies used on the patient such as bandages, casts, crutches, etc.

However, the present invention is not limited to extracting the patient encounter information described and other types of patient encounter information can also be extracted.

One type of medical codes automatically generated at Step 106 (and Step 118 described below) includes CPT E/M codes for new outpatient visits. Table 4 illustrates a few exemplary such medical codes and their corresponding requirements. The codes in Table 4 illustrate only a selected few of the many AMA CPT E/M codes and the present invention is not limited to generating these exemplary medical codes. An amount of provider time spent on the patient encounter is also determined.

TABLE 4 New Outpatient: CPT Code 99201 HX: EXPF PX: EXPF CX: SF Provider Time: 10 minutes New Outpatient: CPT Code 99202 HX: EXPF PX: EXPF CX: SF Provider Time: 20 minutes New Outpatient: CPT Code 99203 HX: DET PX: DET CX: LOW Provider Time: 30 minutes New Outpatient: CPT Code 99204 HX: COMP PX: COMP CX: MOD Provider Time: 45 minutes New Outpatient: CPT Code 99205 HX: COMP PX: COMP CX: HIGH Provider Time: 60 minutes

Another type of medical code generated at Step 106 and 118 includes AMA CPT codes for established outpatient visits. Table 5 illustrates such exemplary codes and their corresponding requirements. The codes in Table 5 illustrate only a selected few of the many CPT E/M codes and the present invention is not limited to generating these exemplary medical codes. The present invention is not limited to the CPT E/M codes illustrated and the present invention implements all and/or selected ones of the possible CPT E/M.

TABLE 5 Established Outpatient: CPT Code 99212 HX: PF PX: PF CX: SF Provider Time: 10 minutes Established Outpatient: CPT Code 99213 HX: EXPF PX: EXPF CX: LOW Provider Time: 15 minutes Established Outpatient: CPT Code 99214 HX: DET PX: DET CX: MOD Provider Time: 25 minutes Established Outpatient: CPT Code 99215 HX: COMP PX: COMP CX: HIGH Provider Time: 40 minutes

According to current AMA CPT guidelines, time is only to be used to determine the level of E/M code if greater than 50% of the face-to-face time of the encounter involved counseling or coordination of care. If applicable coding guidelines are revised at some future date, then time may be factored as indicated by these changes.

Step 106 further includes creating a coding summary of the one or more medical codes generated from the extracted patient encounter information. The created coding summary is attached to the one or more digital images. The coding summary is used to verify that the proper medical codes were generated from the extracted patient encounter information and can be used by auditors to verify the proper medical codes were generated.

FIG. 7 is a Method 110 for automatically calculating a medical code from patient encounter. At Step 112, one or more digital images created from a paper medical information template 12 are securely received on a server computer 20 via a communications network 24. The digital images of the medical information template were created by scanning a paper copy of the medical information template 12 into the medical records system 10 via the scanner 14. At Step 114, the one or more digital images are automatically processed on the server computer 20 to extract patient encounter information. At Step 116, historical information, physical examination information, complexity information, diagnosis, clinical procedures, tests, supplies and other data are collected from the extracted patient encounter information. At Step 118, one or more medical codes are automatically generated from the information collected from the extracted patient encounter information. The one or more medical codes generated include, but are not limited to, one or more of E/M, CPT, HCPCS, ICD-9 ICD-10, or other medical codes. At Step 120, an electronic invoice template and an electronic medical record template are automatically generated in real-time using the one or more generated medical codes collected from the extracted patient encounter information. At Step 122, the electronic invoice template and the electronic medical record templates are displayed in real-time via a computer screen, printed report or utilized or transferred electronically to another software program, database or another data processing system.

Step 118 further includes creating a coding summary of the one or more medical codes generated from the extracted patient encounter information. The created coding summary is attached to the one or more digital images. The coding summary is used to verify that the proper medical codes were generated from the extracted patient encounter information and can be used by auditors to verify the proper medical codes were generated.

FIG. 8 is a block diagram illustrating an exemplary HX matrix 124. The HX matrix 124 is used to determine a history value from the historical information extracted from the patient encounter and used is to generate the medical codes. The HX matrix includes fields for the CC, HPI, PFMSH and ROS elements as described above.

FIG. 9 is a block diagram illustrating an exemplary PX matrix 126. The PX matrix 126 is used to determine a physical examination value from the physical examination extracted from the patient encounter and is used to generate the medical codes. The PX matrix includes fields for the PF, EXPF, DET and COMP elements as described above and a count of the check-boxes extracted as described in Table 3 above.

FIG. 10 is a block diagram illustrating an exemplary CX matrix 128. The CX matrix 128 is used to determine a complexity value from the complexity information extracted from the patient encounter and is used to generate the medical codes. The CX matrix includes fields for DX and RISK and the SF, LOW, MOD and HIGH elements as described above.

FIG. 11 is a block diagram illustrating an exemplary final E/M matrix 130 for a new outpatient. In one embodiment, the E/M matrix 130 is stored as data bits in a computer readable medium on the client network device 18. The final E/M matrix 130 is used to calculate a medical code with the historical value, the physical examination value and the complexity value determined from the HX 124, the PX 126 and the CX 128 matrices. The final E/M matrix 130 includes possible values determined from the HX, PX and CX matrices. It also includes a set of medical codes that can be calculated. FIG. 11 illustrates a set of CPT E/M codes, only for 99201 through 99205 as illustrated in Table 4. FIG. 11 is exemplary only and the invention is not limited to this E/M matrix. The invention includes other plural matrices to generate other types of medical codes.

FIG. 12 is a block diagram illustrating an exemplary final E/M matrix 132 for an established outpatient. The final E/M matrix 132 also includes values determined from the HX, PX and CX matrices. It also includes a set of medical codes that can be calculated. FIG. 12 illustrates a set of CPT E/M codes, only for 99212 through 99215 as illustrated in Table 5. In this example, only two of the three aspects of the HX, PX, and CX need meet the level for the final code. FIG. 12 is exemplary only and the invention is not limited to this E/M matrix. The invention includes plural other matrices to generate other types of medical codes.

Method 110 is illustrated with an exemplary simple patient encounter. An 18-year female patient arrives at a family practice office as a new patient complaining of an acute bee sting on her right fifth finger. She indicates that she has no chronic medical problems, is using no medications and is not known to have a severe allergy to bee stings. She has only minor swelling and no other symptoms. The provider records the patient history on paper medical information template 34, and the provider checks a only small number of check-boxes for the physical exam, template 40 and a minor, new problem in box 41 of FIG. 2B. The patient encounter information is processed with Steps 112, 114 and 116 of Method 110.

At Step 116, referring to FIG. 8, a history value is determined from the HX matrix 124 using the historical information collected from the patient encounter and stored in the internal data structures. Since the chief complaint (“CC”) is a bee sting, the history of the present illness (“HPI”) is brief, the medical history is collected (i.e., not allergic to bee strings, no chronic medical problems, on no medications, etc.) and the review of systems (“ROS”) is limited to constitutional and respiratory systems, the history value returned from the HX matrix is EXPF for a “extended problem focused” complaint.

At Step 116, referring to FIG. 9, a physical examination value is determined from the PX matrix 126 using the physical examination information collected from the patient encounter. The physical exam could be a PF value.

At Step 116, Referring to FIG. 10, a complexity value is determined from the CX matrix 128 using the complexity information collected from the patient encounter. Since a local bee sting reaction is a minor, self-limited problem, DX value is one. The patient may be given over-the-counter medications so the RISK score is two. This makes the complexity value (“CX”) a straight forward, or SF value.

At Step 118, referring to FIG. 11, a medical code is generating from the final E/M matrix 130 for a new outpatient using the history value of EXPF from the HX matrix 124, the physical examination value of PF from the PX matrix 126, and the complexity value of SF from the CX matrix 128. The exemplary medical code and billing code generated is 99201.

Method 110 is illustrated with a second more complex exemplary patient encounter. A 58-year male established patient arrives at a family practice physician office complaining of acute onset of one hour of 10/10 chest pain, accompanied by shortness of breath. The patient suffers from chronic diabetes, has had his left leg amputated and has advanced heart disease, lung disease and kidney disease. There is a history of diabetes in his family and he is currently a heavy smoker of cigarettes. The provider records the patient encounter on paper medical information template 30 for which the provider checks a large number of check boxes and fills in a large number of blanks for the patient encounter including multiple check-boxes in box 41 of FIG. 2B.

At Step 116, referring to again FIG. 8, a history value is determined from the HX matrix 124 using the historical information collected from the patient encounter. Since the chief complaint (“CC”) is pain; the history of the present illness (“HPI”) is extended including four or more elements (location, chest; associated symptoms, shortness of breath; duration, one hour; severity 10/10); the past family, medical and social history is relevant and includes elements of both the medical and social history. (e.g., leg amputation, pain in fingers and kidney disease related to diabetes, heart and lung disease related to heavy smoking, older male) and the review of systems (“ROS”) includes multiple (10) systems (e.g., constitutional, neurological, cardio-vascular, respiratory, etc.), the history value returned from the HX matrix is COMP for a comprehensive history.

At Step 116, referring again to FIG. 9, a physical examination value is determined from the PX matrix 126 using the physical examination information collected from the patient encounter. All elements identified by a bullet in over 9 areas/systems are documented in FIG. 2B so a COMP value (comprehensive exam) is generated.

At Step 116, referring again to FIG. 10, a complexity of medical decision making value is determined from the CX matrix 128 using the complexity information collected from the patient encounter. Since the problems are new and additional workup is planned, the detailed exam (“DX”) value is four. Since the risk of morbidity or mortality is high based on the life-threatening nature of the patient's presentation, chief complaint the RISK value is also four. This makes the complexity of medical decision making value a HIGH value.

At Step 118, referring to FIG. 12, a medical code is generated from the final E/M matrix 132 for an established outpatient using the history value of COMP from the HX matrix 124, the physical examination value of COMP from the PX matrix 126, and the complexity of medical decision making value of HIGH from the CX matrix 128. The medical code generated is 99215. (See also Table 5).

FIGS. 2C and 2D are a block diagram 133 illustrating a front side 135 and a back side 137 of another exemplary paper medical information form that further illustrates an exemplary coding summary 139 produced from exemplary patient encounter information.

The patient encounter illustrated in FIGS. 2C and 2D is fictitious and not the result of a real patient encounter. Thus, this fictitious medical data does not violate the privacy of any real individual under HIPAA or other federal or state laws.

This fictitious patient, a new outpatient, complained of a cough, chills, and tightness in the chest. During the patient encounter various boxes on the paper information template were checked off including a check of the patient's neck (box 40 FIG. 2D and normal green box 44 illustrated in FIG. 3). A diagnosis was also made in the Diagnoses box (new w/u complete box 41 FIG. 2D and FIG. 3) and the provider included handwritten notes. The provider spent about 30 with the patient.

The exemplary coding summary 139 is attached to the one or more digital images after the one or more medical codes are generated. The exemplary coding summary in box 139 is also illustrated in Table 6.

TABLE 6 CODING SUMMARY OUTPUT FROM PROCESSING OF EXEMPLARY PAPER MEDICAL INFORMAITON FORM ILLUSTRATED IN FIGS. 2C and 2D (box 139) E/M=99203 History=DET (CC=COMP; HPI=COMP; PFMSH=DET; ROS=DET) Exam=DET (13 Bullets; 6 Systems) / Complexity of MDM=MOD (DX=MOD; RISK=MOD; Data=N/A)

As FIGS. 2C and 2D and Table 6 illustrate, an exemplary E/M code generated from this fictitious patient encounter was 99203 for a new outpatient (Table 5 and FIG. 11). The exemplary E/M code of 99203 is generated with the methods described herein.

Table 7 illustrates an exemplary invoice automatically generated from the information in Table 6. However, the present invention is not limited to such an exemplary invoice and other invoices can also be automatically generated and used to practice the invention.

TABLE 7 ERgent Care Clinic Patient: John Doe (New) Date: 10-18-2003 Time: 12:00 p.m. Chief Complaint: Cough and chest Congestion Exam: Detailed Exam chills Fee: $59.00 Doctor: Dr. Janet Smith Insurance: Blue Cross - Blue Shield Risk/Complexity: Moderate Expected Insurance Payment: $35.00 Total Due from Patient: $14.00 Exit Instructions: Fill prescription for DOXYCYCLINE, see family physician within three days.

FIG. 13 is a flow diagram illustrating a Method 134 of processing medical information templates via a medical records system. At Step 136, electronic data created from an electronic medical information template 12′ is securely received on a server computer 20 via a communications network 24. The electronic data was created on a client network devices 18 using an electronic medical information template 12′. At Step 138, the electronic data is automatically processed on the server computer 20 to extract patient encounter information. At Step 140, one or more medical codes are automatically generated from the extracted patient encounter information. The one or more medical codes generated include, but are not limited to, one or more of E/M, CPT, HCPCS, ICD-9, ICD-10, or other types of codes. At Step 142, the one or more medical codes generated from the extracted patient encounter information are presented on one or more electronic templates that are displayed on a graphical user interface (GUI) or the one or more electronic templates are utilized to produce additional medical information documents. The one or more electronic templates include, but are not limited to, an electronic invoice template, an electronic medical record template, a current compliant template, a nurse template, a review template, a diagnosis template; a provider template; and other types of electronic templates electronically to another software program, database or another data processing system.

Method 134 is used to process digital data extracted patient encounter information entered on client network devices 18 using an electronic medical information template 12′ instead of a paper medical information template. Method 134 processes such electronic data in a manner similar to the digital images described for Methods 100 and 110.

FIG. 14 is a flow diagram illustrating a Method 144 of processing medical information templates via the medical records system. At Step 146, one or more medical codes are generated automatically from patient encounter information extracted from one or more digital images created from a paper medical information template 12 for an encounter with a patient. The one or more medical codes generated include, but are not limited to, one or more of E/M, CPT, HCPCS, ICD-9, IDC-10, or other medical codes. At Step 148, one or more electronic templates are generated automatically using the one or more generated medical codes and other information extracted from the extracted patient encounter information. The one or more electronic templates include, but are not limited to, an electronic invoice template, an electronic medical record template, a current compliant template, a nurse template, a review template, a diagnosis template; a provider template; and other types of electronic templates. At Step 150, the one or more electronic templates that are displayed on a graphical user interface (GUI) or the one or more electronic templates that are utilized to produce additional medical information documents including the one or more medical codes generated from the extracted patient encounter information and other information extracted from the extracted patient encounter information.

Step 146 further includes creating a coding summary of the one or more medical codes generated from the extracted patient encounter information. The created coding summary is attached to the one or more digital images. The coding summary is used to verify that the proper medical codes were generated from the extracted patient encounter information and can be used by auditors to verify the proper medical codes were generated.

The methods and systems described herein were illustrated with respect to a patient examination view or perspective. However, the invention is not limited to this view or perspective. The methods and system described herein are also used to provide automated processing and real-time collection and display of other types of medical information associated with, or generated by a patient encounter to provide 360° view of an individual patient after a patient encounter. The methods and system are used to process, display and/or utilize in real-time all available information for a patient immediately after a patient encounter.

Although description of this method has been limited to the outpatient encounter, this same methodology may be applied to documentation and coding of in-hospital encounters, consults, preventative examinations and other types of patient encounters.

FIG. 15 is a block diagram illustrating a 360° real-time view 152 of a patient encounter. The 360° real-time view includes, but not limited to, HX 154, PX 156, CX 158 matrix information extracted, diagnostic procedures ordered 160 (e.g., blood tests, x-rays, MRI scans, CT scans, etc.); diagnostic procedures results 162; treatment plans 164; referral information 166; dictation information 168; patient insurance information 170; provider information 172; and information such drug testing information 174, workmen's comp information 176, legal information 178, and other types of information 180 associated with a patient and/or a patient encounter.

Processing Patient Encounter Information from Electronic Medical Information Templates

FIG. 16 is a flow diagram illustrating a Method 182 for automated processing of medical information. At Step 184, patient encounter data collected from a patient encounter on an electronic medical template is aggregated in real-time on a first application on a first network device with one or more processors. The patient encounter data is aggregated into plural information matrixes stored in a computer readable medium on the first network device associated with the first application including: a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, each with plural matrix information fields stored in the computer readable medium. The CX information matrix helps eliminate an amount and complexity of patient encounter data collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a medical risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed. At Step 186, plural summary values are generated from the plural information matrixes via the first application. At Step 188, one or more medical and billing codes are generated via one or more summary information matrixes using the plural summary values generated from the plurality of information matrixes via the first application. At Step 190, an electronic patient medical record is generated from the aggregated patient encounter data and one or more generated medical and billing codes. At Step 192, the generated electronic patent medical record generated from the patent encounter is displayed in real-time via the first application on the first network device via a graphical user interface (GUI) the electronic including complexity risk information for the patient encounter. The electronic medical record provides a 360 degree real-time view of medical, billing, insurance and other information collected and generated from the patient encounter.

Method 182 is illustrated with one exemplary embodiment. However, the present invention is not limited to such an exemplary embodiment and other embodiments can also be used to practice the invention.

In such an exemplary embodiment at Step 184, patient encounter data collected from a patient encounter (FIGS. 2D, 2D displayed electronically instead of using paper templates) on an electronic medical template 12′ is aggregated on a first application 26 (e.g., 28, 30, 32, 33, etc.) on a first network device 18 with one or more processors. The patient encounter data is aggregated into plural information matrixes stored as data bits in a computer readable medium on the first network device 18 associated with the first application including: a historical information (HX) matrix 124, a patient examination (PX) matrix 126 and a complexity risk (CX) information matrix 128, each with plural matrix information fields (e.g., Tables, 1-5, FIGS. 8-10). The CX information matrix 128 helps eliminate an amount and complexity of patient encounter data collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a medical risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed.

At Step 186, plural summary values are generated from the plural information matrixes 124, 126, 128 directly on the client network device 18. In another embodiment, the first application on the client network device 18 also establishes a communication via communications network 24 to server computer 20 and database 22 is used to generate additional summary values for the patient.

For example, if the patient is an established patient at the medical facility visited, then existing electronic medical information about the established patient can be retrieved from the database 22 and automatically added to the summary values. In one specific example, the additional summary values added may include existing medications prescribed to the patient, drugs the patient is allergic to, etc. Such an automatic update of the summary values helps lower the risk and complexity associated with the patient encounter as most medical patients do not have a clear understanding and do not clearly remember what medications may have been prescribed to them or exactly what drugs they may allergic to. A similar query may also be made to the patient medical insurance company to automatically obtain insurance coverage information. This helps lower the risk and complexity associated with insurance billing and/or collecting immediate payment from a patient after a patient encounter. However, such a query can only be made if the patient's medical insurance company has an electronic interface to provide such information.

In another embodiment, the methods and system described herein, including the dataflow 52 of FIG. 4 can be used to input paper insurance records for the patient. In such an embodiment, all of the patient's insurance information would then be available electronically.

If the patient is a new patient at the medical facility visited, a query may be made to automatically obtain the new patient medical records. The new patient medical records are automatically processed to generate additional summary values from the medical records. However, such a query can only be made if the patient's medical provider has an electronic interface to provide electronic medical records.

In another embodiment, the methods and system described herein, including the dataflow 52 of FIG. 4 can be used to input paper medical records for the patient. In such an embodiment, all of the patient's previous medical information from the medical records would then be available electronically.

In such embodiments, any information obtained from the quires to database 22 for any additional medical and/or insurance information is added to the summary values and/or used to create an additional type and count of the electronic check boxes used on the medical information templates and/or via the matrixes.

At Step 188, one or more medical and billing codes are generated via one or more Evaluation and Management (E/M) summary information matrixes 130, 132 using the plural summary values generated from the plurality of information matrixes (e.g., Table 6, FIGS. 11, 12, etc.)

At Step 190, an electronic patient medical record is generated from the aggregated patient encounter data and one or more generated medical and billing codes.

At Step 192, the generated electronic patent medical record generated from the patent encounter is displayed in real-time via the first application 32 on the first network device 18 via a graphical user interface (GUI) including complexity risk information 154 for the patient encounter. The electronic medical record provides a 360 degree real-time view 152 of medical, billing, insurance and other information collected and generated from the patient encounter (e.g., FIG. 15).

In one exemplary embodiment, FIG. 5 illustrates an exemplary data flow and FIG. 15 illustrates an exemplary real-time 360 degree view for the patient encounter described for Method 182 of FIG. 16. However, the present invention is not limited to these exemplary embodiments and other embodiments can also be used to practice the invention.

FIG. 17 is a block diagram of a screen shot 194 of a first portion 196 of an exemplary electronic medical information template.

FIG. 18 is a block diagram of a screen shot 206 of a second portion 208 of an exemplary electronic medical information template,

FIG. 19 is a block diagram of a screen shot 220 of a third portion 222 of an exemplary electronic medical information template.

FIG. 20 is a block diagram of a screen shot 234 of a fourth portion 236 of an exemplary electronic medical information template.

FIG. 21 is a block diagram of a screen shot 228 of a fifth portion 230 of an exemplary electronic medical information template.

FIG. 22 is a block diagram of a screen shot 248 of a sixth portion 250 of an exemplary electronic medical information template.

FIGS. 17-23 are copyright © by Practice Velocity, LLC. All rights reserved.

FIGS. 17-23 illustrate portions of exemplary electronic medical information templates 12′ displayed on a client network device 18. However, these portions are exemplary only and many more and different portions for the electronic medical information templates 12′ are displayed on the client network device 18. The portions of the medical information templates 12′ are stored in data structures in the computer readable medium of the client network devices 18.

FIGS. 17-23 illustrate plural portions of electronic medical records templates 12′ generated for an exemplary fictional patient that enters an urgent care clinic as an existing patient that has visited this urgent care clinic before.

The exemplary fictional patient is a 64 year old male named David Smith and is in Exam Room 3. He has a bite wound from an unknown organism (e.g., a spider?, etc.) in the knee area. His application of ice made the bite area feel better. His temperature is 103° F., his blood pressure is 120/80. His pulse is 68 beats-per-minute. His in moderate pain and experiencing chest pain and muscle pain. He has heart problems, has a ventricular stunt installed, has had recent head and/or neck surgery. He is allergic to Penicillins.

FIG. 17 illustrates a first portion 196 of an exemplary electronic medical information template 12′. The first portion 196 is automatically and specifically sized to be displayed on a selected client network device 18. FIG. 17 illustrates two exemplary check boxes in a checked position 198. FIG. 17 illustrates a first portion of a medical information template to collect information about a new chief complaint (CC). In this example, the CC is a bite wound to the knee area.

FIGS. 17-23 illustrate a selection bar 200 that is selected to display various other portions of the electronic medical information template 12′. In embodiment, the graphical selection bar 200 includes graphical tabs to select portions corresponding directly to information collected for the HX, PX and CX matrixes 124, 126, 128 described above. However, the present invention is not limited to this embodiment and the graphical selection bar 200 can include other graphical tabs and other graphical selection bars can also be used to practice the invention. For example, in another embodiment, the selection bar 200 may not make any direct reference to any the monikers used in the matrixes.

The graphical selection bar 200 also includes graphical tabs to display the generated medical and billing codes 202 and the generated electronic medical record 204.

FIG. 18 illustrates a second portion 208 of the exemplary electronic medical information template 12′ including a Review Of Systems (ROS) portion. ROS was described above (e.g., Table 1b for the HX matrix 124, etc.). The second portion 208 is automatically and specifically sized to be displayed on a selected client network device 18.

The second portion 208 illustrates plural columns of green check boxes 210 (leftmost column) and plural columns of red of check boxes 212 (middle column). As was described above the green check box indicates the provider examined the patient, but the patient does not have any abnormality in the indicated body area or system. The red check box indicates the provider examined the patient, but the patient does have one or more abnormalities in the indicated body area or system. Plural green and red check boxes in the checked position are illustrated in FIG. 18.

FIG. 18 also illustrates a third column of gray check boxes to the right the red check boxes. The display order on FIG. 18 is green, red, gray. In one embodiment, the gray check boxes are used to collect data for medical research studies and/or for statistical purposes, etc. The data collected by the grey check boxes is identified by a patient identifier that can be mapped back to the patient the data is collected from during the patient encounter. However, the data is stored just with a numeric patient identifier, so of the data is comprised, it does not violate any patient privacy rights under HIPAA.

In another embodiment, the third column of gray check boxes is used for specific practice types to provide additional data inputs to the HX, PX, CX and E/M matrixes 124, 126, 128, 130, 132 stored in the computer readable medium on the client network device 18.

However the present invention is not limited to the number or color or purpose of check boxes described and more, fewer and other types of numbers, purposes and colors of check boxes can also be used to practice the invention. In addition, the check boxes can be replaced with other graphical features (e.g., radio buttons, bullet buttons, etc.) that can be displayed in an on and off position by selecting and/or deselecting the graphical feature. Check boxes were used on the electronic medical information templates 12′ since they were created and in some embodiments are identical to the paper medical information templates 12 used and described above.

For example, as is illustrated in FIG. 18, the exemplary patient with the bite wound to the knee has chest pain 214 and muscle pain 216 illustrated by a check mark in the red boxes for those recent symptoms. Additional text is entered 215, 217 by the provider via the client network device 18 to further describe the chest pain 214 and the muscle pain 216. The physician may also dictate additional details about the patient encounter into the dictation interface 27.

The exemplary patient does not have any of the other symptoms illustrated by the check mark in the green boxes for the other recent symptoms in the Constitutional box 218 such as no change in appetite, no fever, no chills, no sweats, no chest pressure, no fatigue, no weight loss, etc.

FIG. 19 illustrates a third portion 222 of the exemplary electronic medical information template 12′ including a Personal Family and Social History (PFSH) portion. PFSH was described above (e.g., Table 1b for the HX matrix, etc.). The third portion 222 is automatically and specifically sized to be displayed on a selected client network device 18. The third portion 222 illustrates the patient is allergic to Penicillins 224, and plural red check boxes are checked for the exemplary patient including heart problems 226, head/neck surgery 228, ventricular stunt 230, and a smoker 232. When the red check boxes are checked, the font on the electronic medical information template 12′ is changed to a bold font to make it easier for a viewer to visually determine a symptom from the patient encounter. Also, colored warning symbols (e.g., 225) are used (e.g., in box 224 for the allergy to Penicillins, etc.) indicate additional warnings to the physician. Box 224 illustrates one type of medical information for an established patient that may be queried and obtained from server computer 20 and added to the electronic medical information template 12′ for the patient encounter.

FIG. 20 illustrates a fourth portion 236 of the exemplary electronic medical information template 12′ including a medical and/or diagnostic procedures ordered 160 portion 236. The fourth portion 236 is automatically and specifically sized to be displayed on a selected client network device 18. The fourth portion 236 currently illustrates a lab test tab 238 selected. The lab test tab 238 displays available lab and diagnostic tests that can be selected for the patient.

FIG. 21 is a block diagram of a screen shot 240 of a fifth portion 242 of an exemplary electronic medical information template. The fifth portion 242 illustrates a summary of the information collected via the HX, PX, CX and E/M matrixes and displayed under the Code Summary 4 tab 202 (FIG. 17). FIG. 22 illustrates a first box 244 for displaying a count of matrixes values 124, 126, 128 determined by check boxes checked on the various portions of the electronic medical information template 12′. Box 244 illustrates History, CC/HPI, ROS, PFSH, Physical and Data with a number five. Complexity, DX and Risk with number four. It also illustrates a suggested Final Code of a number four and a final E/M code of 99214 (132, FIG. 12) for an established patient.

FIG. 21 also illustrates a second box 246 that includes a coding summary of the one or more medical and billing codes generated by Method 182 (and other methods described herein) from the exemplary electronic medical information template 12′ portions illustrated in FIGS. 17-23. Table 8 illustrates the coding summary displayed in Box 246 (e.g., 99214, etc.) determined from E/M matrix 132 (FIG. 12).

The final E/M code 247 generated for this patient is 99214 (see FIG. 12) based on the values determined from the checked boxes and applied to matrixes HX, PX, and CX illustrated in FIGS. 8-10. The final ICD9 codes generated include 786.59 and 034.0.

TABLE 8 CODING SUMMARY OUTPUT FROM PROCESSING OF EXEMPLARY ELECTRONIC MEDICAL INFORMATION TEMPLATE 12′ PORTIONS ILLUSTRATED IN FIGS. 17-23 and displayed in Box 246 on FIG. 21 Suggested E/M = 99214 (using 1995 guidelines...) (item 247 FIG. 21) History=Comprehensive (CC/HPI = Extended: PFSH = Complete; ROS = Complete) Exam=Comprehensive (8 systems) Complexity=Moderate Complexity (DX=Multiple, Risk=Moderate; DR=Extensive) ICD9 786.59 - Chest Pain 034.0 - Sore Throat XRAY 71020 - Chest 2 views, frontal and lateral LAB 87880 - Strep Group A

FIG. 22 is a block diagram of a screen shot 248 of a sixth portion 250 of an exemplary electronic medical information template 12′. The sixth portion 250 illustrates an exemplary electronic medical record 252 automatically generated in real-time from the patient encounter as the result of Method 182 (and other methods described herein. In one embodiment, the exemplary medical record is displayed by selected and displayed by selecting the Medical Record tab 202 (FIG. 17). Any symptoms that the patient is encountering and were collected during the patient encounter are displayed in a different font color (e.g., red and bold) for easy viewing on the medical record 252. For example, the chest pain 214 and muscle pain 216 collected from the red check boxes on FIG. 18 are displayed in the different color fonts on the medical record 252 in FIG. 22. In one embodiment, the electronic medical record 252 also displays the coding summary including the final E/M code 247. In another embodiment, the final E/M code 247 is not displayed on the electronic medical record 252. However, the present invention is not limited to this embodiment and other embodiments can also be used to practice the invention.

As is illustrated in FIGS. 17-23, plural portions of the electronic medical information templates 12′ are automatically and successively displayed and automatically and specifically sized to be displayed on a selected client network device 18.

FIG. 23 is a block diagram of screen 254 shot illustrating an exemplary first portion 196 of a medical information template on a smart phone 256. In one exemplary embodiment, the application 26 (28, 30, 32, 33) is an application for a iPhone, by Apple, Inc as illustrated in FIG. 23. However, the present invention is not limited to such an embodiments and other embodiments, can also be used to practice the invention.

In one embodiment, the portions of the electronic medial information templates 12′ displayed are identical to portions of the paper medical information templates 12. In another embodiment, the portions of the electronic information templates 12′ are not identical to portions of the paper medical information template 12. In such an embodiment, the portions of the electronic information templates 12′ displayed by the client network device 18 may appear in different orders, different sequences, different groups, etc. However, the methods described herein to automatically process medical information from the electronic medical information templates 12′ are used no matter how the electronic templates 12′ are portioned and/or displayed on the client network device.

The method and system help automate and reduce the risk and complexity of collecting patient encounter information electronically on client network devices 18 and allow easy collection, processing and recording of medical information codes such as diagnosis codes, billing codes, insurance codes, etc.

In view of the wide variety of embodiments to which the principles of the present invention can be applied, it should be understood that the illustrated embodiments are exemplary only, and should not be taken as limiting the scope of the present invention. For example, the steps of the flow diagrams may be taken in sequences other than those described, and more fewer or equivalent elements may be used in the block diagrams.

The claims should not be read as limited to the described order or elements unless stated to that effect. In addition, use of the term “means” in any claim is intended to invoke 35 U.S.C. §112, paragraph 6, and any claim without the word “means” is not so intended.

Therefore, all embodiments that come within the scope and spirit of the following claims and equivalents thereto are claimed as the invention. 

We claim:
 1. A method for automated processing of medical information, comprising: generating dynamically via a first application on a first network device with one or more processors, one or more different electronic medical templates on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via a second application on a second network device with one or more processors and one or more associated databases; creating dynamically via the first application in the one more different medical templates a plurality of data fields stored in a non-transitory computer readable medium on the first network device comprising: patient history data comprising at least past medical, family, social history (“PMSFH”), allergies and medications, patient physical condition data comprising at least a chief complaint and vital signs, medical summary information comprising at least a review of present systems (“ROS”) and type of exam information, existing patient history information comprising at least a history of present illness (“HPI”), and complexity risk information comprising at least diagnosis (“DX”) or treatment options and a plurality of risk (“RISK”) information; accepting patient encounter information via a graphical user interface (GUI) via the first application from a patent encounter into the plurality of created data fields on the one or more different electronic medical templates, thereby creating a completed electronic form for the patient encounter; generating from the first application a plurality of summary information matrixes in the non-transitory computer readable medium on the first network device, the plurality of summary information matrixes including: a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, wherein the HX information matrix includes a plurality of matrix information elements comprising: a chief complaint (“CC”), history of present illness (“HPI”), past medical, family, social history information (“PFMSH”) elements or review of system (“ROS”) information elements, wherein the PX information matrix includes a plurality of matrix information elements comprising: (“PF”) exam information for a general exam; an expanded problem focused exam (“EXPF”) a detailed exam (“DET”) or comprehensive exam (“COMP”) information elements, and wherein the CX information matrix includes a plurality of matrix information elements comprising: diagnosis (“DX”) or treatment options information elements including a straight forward (“SF”) diagnosis, low risk (“LOW”) number of diagnosis, a moderate number of (“MOD”) diagnosis or a high (“HIGH”) number of diagnosis and a plurality of risk (“RISK”) information elements including straight forward (“SF”) risk information, low risk (“LOW”) information, moderate risk (“MOD”) information or high risk (“HIGH”) information; aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data from the first application on the first network device in real-time, wherein the aggregated medical data is aggregated into the plurality of summary information matrixes stored in the non-transitory computer readable medium on the first network device associated with the completed medical form; calculating from the first application a plurality of medical and billing codes and a plurality of risk codes with selected ones of the plurality of matrix information elements from each of the plurality of summary information matrixes including the aggregated medical data accepted from the patient encounter; creating automatically a new electronic medical record with a plurality of information fields in real-time via the first application on the first network with the aggregated medical data, the plurality of summary information matrixes, the calculated plurality of medical and billing codes and the calculated plurality of risk codes and a plurality of other summary medical information including: one or more medical and billing code modifiers, legal compliance for medical treatment provided to a patient during the patient encounter, an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter, a physician practice profile by aggregating data for a particular physician, an amount of time spent during the patient encounter; complexity risk information, laboratory and diagnostic test results completed during the patient encounter, data for use in research studies, and billing and invoice data; providing in real-time the created new electronic medical record via the first application on the first network device for display on the GUI, thereby providing a complete 360 degree view of medical, complexity risk, billing, insurance and other information collected and generated from the patient encounter; categorizing and limiting via the first application a selected number of medical diagnoses or medical management options in the created new electronic medical record, thereby reducing a medical risk and complexity associated with the patient encounter; calculating a risk complexity value for the patient encounter from the categorized and limited created new electronic medical record; extracting in real-time from the first application selected ones of elements from the categorized and limited created new electronic medical record and creating a summary information matrix for the patient encounter, wherein the summary information matrix limits an amount and complexity of patient data to be reviewed and a number of diagnostic options to be considered for the patient encounter; displaying in real-time via the first application on the first network device via the GUI electronic information generated from the created summary information matrix and extracted from the categorized and limited created new electronic medical record and the calculated risk complexity value in one or more different colors than are used to display other electronic information from the created electronic medical record, thereby further reducing the medical risk associated with making a medical decision for the patient encounter using the displayed created summary information matrix; and generating in real-time from the first application a patient invoice for the patient encounter via the categorized and limited created new electronic medical record and the one or more generated medical and billing codes for immediate presentation to the patient after the patient encounter, thereby reducing a risk and complexity associated with insurance billing and reducing a risk and complexity associated with collecting immediate payment from the patient after the patient encounter.
 2. The method of claim 1 wherein the one or more different electronic medical templates includes a plurality of electronic check-boxes including a plurality of different colors specifically selected for a specific type of medical practice, wherein processing the plurality of electronic check-boxes generates an appropriate number and type of medical and billing codes for the specific type of medical practice.
 3. The method of claim 2, wherein the plurality of electronic check-boxes including a plurality of different colors includes a plurality of green and red check-boxes, wherein a green check box indicates medical personal examined the patient during the patient encounter, but the patient does not have any abnormality in a body area or body system indicated by the check-box and a red check box indicates the medical personal examined the patient during the patient encounter, but the patient does have one or more abnormalities in the body area or body system indicated by the check-box.
 4. The method of claim 1 further comprising: aggregating patient encounter data collected from the patient encounter on the created electronic medical template on the first application on the first network device with one or more processors into the plurality of information matrixes stored in the non-transitory computer readable medium on the first network device associated with the first application including: a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, each with a plurality of matrix information fields; wherein the CX information matrix helps eliminate an amount and complexity of patient encounter data collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a medical risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed; generating a plurality of summary values from the plurality of information matrixes in real-time on the first application; generating one or more medical and billing codes via one or more summary information matrixes using the plurality of summary values generated from the plurality of information matrixes in real-time on the first application; generating a complete electronic patient medical record from the aggregated patient encounter data and one or more generated medical and billing codes in real-time on the first application; and displaying in real-time via the first application on the first network device via a the graphical user interface (GUI) the generated complete electronic patient medical record generated from the patient encounter including complexity risk information for the patient encounter, wherein the generated complete electronic medical record provides a complete real-time 360 degree view of medical, billing, insurance and other information collected and generated from the patient encounter immediate payment from a patient immediately after the patient encounter.
 5. The method of claim 4 wherein the HX information matrix includes a plurality of matrix information elements comprising: a chief complaint (“CC”), history of present illness (“HPI”), past medical, family, social history information (“PFMSH”) elements or review of system (“ROS”) information elements, wherein the PX information matrix includes a plurality of matrix information elements comprising: (“PF”) exam information for a general exam; an expanded problem focused exam (“EXPF”) a detailed exam (“DET”) or comprehensive exam (“COMP”) information elements, and wherein the CX information matrix includes a plurality of matrix information elements comprising: diagnosis (“DX”) or treatment options information elements including a straight forward (“SF”) diagnosis, low risk (“LOW”) number of diagnosis, a moderate number of (“MOD”) diagnosis or a high (“HIGH”) number of diagnosis and a plurality of risk (“RISK”) information elements including straight forward (“SF”) risk information, low risk (“LOW”) information, moderate risk (“MOD”) information or high risk (“HIGH”) information.
 6. The method of claim 4 wherein the one or more medical codes and billing codes include one or more of Evaluation and Management codes (“E/Ms”) codes, Current Procedural Terminology (“CPTs”) codes, Health Care Financing Administration Common Procedural Coding System (“HCPCS”) codes International Classification of Diseases 9^(th) Edition Clinical Modification (“ICD-9”) codes, or International Classification of Diseases 10^(th) Edition Clinical Modification (“ICD-10”) codes.
 7. The method of claim 4 wherein the step of aggregating patient encounter data further includes: automatically making one or more queries to a second application on a second network device via a communications network to obtain electronic medical records or electronic medical insurance records for the patient, if any are available and extracting selected ones of pre-determined values from the obtained electronic medical records into a type and count of electronic check-boxes used on the electronic medical template; aggregating patient encounter information from plurality of a electronic check-boxes selected for a specific type of medical practice and displayed on the electronic medical template; determining the type and count of the electronic check-boxes, wherein the type and count of electronic check boxes determines one or more positions in the each of the plurality of information matrixes; and generating one or more medical and billing codes using one or more Evaluation and Management (E/M) information matrix, wherein the positions determined from each of the plurality of information matrixes are used to determine one or more final positions in the E/M information matrix including the one or more medical and billing codes for the patient encounter.
 8. The method of claim 4 further comprising: the HX information matrix including a plurality of information elements stored in the non-transitory computer readable medium comprising: a chief complaint (“CC”), history of present illness (“HPI”), past medical, family, social history information (“PFMSH”) or review of system (“ROS”) information elements, the PX information matrix including a plurality of information elements stored in the non-transitory computer readable medium comprising: (“PF”) exam information for a general exam; an expanded problem focused exam (“EXPF”) a detailed exam (“DET”) or comprehensive exam (“COMP”) information elements, the CX information matrix including a plurality of information elements stored in the non-transitory computer readable medium comprising: diagnosis (“DX”) or treatment options information elements including a straight forward (“SF”) diagnosis, low risk (“LOW”) number of diagnosis, a moderate number of (“MOD”) diagnosis or a high (“HIGH”) number of diagnosis and a plurality of risk (“RISK”) information elements including straight forward (“SF”) risk information, low risk (“LOW”) information, moderate risk (“MOD”) information or high risk (“HIGH”) information; and one or more Evaluation and Management (E/M) summary information matrixes stored in the non-transitory computer readable medium including HX matrix summary values, PX matrix summary values and CX matrix summary values for new patient encounters and established patient encounters.
 9. The method of claim 4 wherein the electronic medical template includes an electronic medical template for pediatrics, obstetrics and gynecology, cardiology, neurology, family practice medicine, emergency room medicine, walk-in clinics or urgent care clinics.
 10. The method of claim 1 further comprising: verifying in real-time the aggregated medical data via the first application on the first network device.
 11. The method of claim 1 wherein the one or more different electronic medical templates include one or more of a medical practice template, electronic invoice template, and electronic medical record template, a current compliant template, a diagnosis template, a nurse template, a review template, or a provider template.
 12. The method of claim 1 wherein the step of aggregating medical data further includes: automatically making one or more queries to the second application on the second network device via the communications network to obtain electronic medical records or electronic medical insurance records for the patient, if any are available and extracting predetermined values from the obtained electronic medical records and used on the one or more different medical information templates; determining one or more history values from the HX information matrix; determining one or more physical examination values from the PX information matrix; determining one or more complexity risk values from the CX information matrix; determining one or more patient status values from patient status information extracted from the patient encounter information from the HX information matrix; determining one or more patient demographic values from patient demographic information extracted from the patient encounter information from the HX information matrix; determining one or more diagnosis values from diagnosis information extracted from the patient encounter information from the CX information matrix; determining one or more clinical procedure values from clinical procedure information extracted from the patient encounter information from the CX information matrix; determining one or more supply values from supply information extracted from the patient encounter information from the HX, PX and CX information matrix; and generating one or more medical and billing codes using the plurality of determined values via one or more summary information Evaluation and Management (E/M) information matrixes.
 13. The method of claim 1 wherein the plurality of calculated medical codes and billing codes include one or more of Evaluation and Management codes (“E/Ms”) codes, Current Procedural Terminology (“CPTs”) codes, Health Care Financing Administration Common Procedural Coding System (“HCPCS”) codes International Classification of Diseases 9^(th) Edition Clinical Modification (“ICD-9”) codes, or International Classification of Diseases 10^(th) Edition Clinical Modification (“ICD-10”) codes.
 14. The method of claim 1 wherein complexity risk coding information helps eliminate an amount and complexity of patient data to be collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed.
 15. The method of claim 1 wherein the plurality of data fields include a plurality of electronic check-boxes includes generating: a plurality of HX data fields including patient history information; a plurality of PX data fields including patient physical condition information; a plurality of CX data fields including complexity risk information; and one or more Evaluation and Management (E/M) data fields including evaluation and management codes, wherein the generated one or more E/M data fields include summary information obtained by aggregating information from the HX, PX and CX data fields.
 16. The method of claim 1 wherein the first network device includes a personal digital/data assistant (PDA), an electronic tablet, an Internet appliance, a mobile phone, a smart phone or an electronic gaming platform.
 17. The method of claim 1 wherein the first network device includes a wireless interface for communicating with the communications network comprising: an IEEE 802.11a, 802.11b, 802.11g, 802.11n, 802.15.4 (ZigBee), 802.16a, 802.16 g, Wireless Fidelity (Wi-Fi), wireless personal area network (WPAN), Worldwide Interoperability for Microwave Access (WiMAX) or ETSI High Performance Radio Metropolitan Area Network (HIPERMAN) wireless interface.
 18. A non-transitory computer readable medium having stored therein a plurality of instructions for causing a one or more processors to execute the steps of: generating dynamically via a first application on a first network device with one or more processors, one or more different electronic medical templates on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via a second application on a second network device with one or more processors and one or more associated databases; creating dynamically via the first application in the one more different medical templates a plurality of data fields stored in a non-transitory computer readable medium on the first network device comprising: patient history data comprising at least past medical, family, social history (“PMSFH”), allergies and medications, patient physical condition data comprising at least a chief complaint and vital signs, medical summary information comprising at least a review of present systems (“ROS”) and type of exam information, existing patient history information comprising at least a history of present illness (“HPI”), and complexity risk information comprising at least diagnosis (“DX”) or treatment options and a plurality of risk (“RISK”) information; accepting patient encounter information via a graphical user interface (GUI) via the first application from a patent encounter into the plurality of created data fields on the one or more different electronic medical templates, thereby creating a completed electronic form for the patient encounter; generating from the first application a plurality of summary information matrixes in the non-transitory computer readable medium on the first network device, the plurality of summary information matrixes including: a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, wherein the HX information matrix includes a plurality of matrix information elements comprising: a chief complaint (“CC”), history of present illness (“HPI”), past medical, family, social history information (“PFMSH”) elements or review of system (“ROS”) information elements, wherein the PX information matrix includes a plurality of matrix information elements comprising: (“PF”) exam information for a general exam; an expanded problem focused exam (“EXPF”) a detailed exam (“DET”) or comprehensive exam (“COMP”) information elements, and wherein the CX information matrix includes a plurality of matrix information elements comprising: diagnosis (“DX”) or treatment options information elements including a straight forward (“SF”) diagnosis, low risk (“LOW”) number of diagnosis, a moderate number of (“MOD”) diagnosis or a high (“HIGH”) number of diagnosis and a plurality of risk (“RISK”) information elements including straight forward (“SF”) risk information, low risk (“LOW”) information, moderate risk (“MOD”) information or high risk (“HIGH”) information; aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data from the first application on the first network device in real-time, wherein the aggregated medical data is aggregated into the plurality of summary information matrixes stored in the non-transitory computer readable medium on the first network device associated with the completed medical form; calculating from the first application a plurality of medical and billing codes and a plurality of risk codes with selected ones of the plurality of matrix information elements from each of the plurality of summary information matrixes including the aggregated medical data accepted from the patient encounter; creating automatically a new electronic medical record with a plurality of information fields in real-time via the first application on the first network with the aggregated medical data, the plurality of summary information matrixes, the calculated plurality of medical and billing codes and the calculated plurality of risk codes and a plurality of other summary medical information including: one or more medical and billing code modifiers, legal compliance for medical treatment provided to a patient during the patient encounter, an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter, a physician practice profile by aggregating data for a particular physician, an amount of time spent during the patient encounter; complexity risk information, laboratory and diagnostic test results completed during the patient encounter, data for use in research studies, and billing and invoice data; providing in real-time the created new electronic medical record via the first application on the first network device for display on the GUI, thereby providing a complete 360 degree view of medical, complexity risk, billing, insurance and other information collected and generated from the patient encounter; categorizing and limiting via the first application a selected number of medical diagnoses or medical management options in the created new electronic medical record, thereby reducing a medical risk and complexity associated with the patient encounter; calculating a risk complexity value for the patient encounter from the categorized and limited created new electronic medical record; extracting in real-time from the first application selected ones of elements from the categorized and limited created new electronic medical record and creating a summary information matrix for the patient encounter, wherein the summary information matrix limits an amount and complexity of patient data to be reviewed and a number of diagnostic options to be considered for the patient encounter; displaying in real-time via the first application on the first network device via the GUI electronic information generated from the created summary information matrix and extracted from the categorized and limited created new electronic medical record and the calculated risk complexity value in one or more different colors than are used to display other electronic information from the created electronic medical record, thereby further reducing the medical risk associated with making a medical decision for the patient encounter using the displayed created summary information matrix; and generating in real-time from the first application a patient invoice for the patient encounter via the categorized and limited created new electronic medical record and the one or more generated medical and billing codes for immediate presentation to the patient after the patient encounter, thereby reducing a risk and complexity associated with insurance billing and reducing a risk and complexity associated with collecting immediate payment from the patient after the patient encounter.
 19. A system for automated processing of medical information, comprising in combination: a plurality of network devices each with one or more processors; a plurality of non-transitory computer readable mediums on the plurality of network devices having stored therein a plurality of instructions configured for: for generating dynamically via a first application on a first network device with one or more processors, one or more different electronic medical templates on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via a second application on a second network device with one or more processors and one or more associated databases; for reating dynamically via the first application in the one more different medical templates a plurality of data fields stored in a non-transitory computer readable medium on the first network device comprising: patient history data comprising at least past medical, family, social history (“PMSFH”), allergies and medications, patient physical condition data comprising at least a chief complaint and vital signs, medical summary information comprising at least a review of present systems (“ROS”) and type of exam information, existing patient history information comprising at least a history of present illness (“HPI”), and complexity risk information comprising at least diagnosis (“DX”) or treatment options and a plurality of risk (“RISK”) information; for accepting patient encounter information via a graphical user interface (GUI) via the first application from a patent encounter into the plurality of created data fields on the one or more different electronic medical templates, thereby creating a completed electronic form for the patient encounter; for generating from the first application a plurality of summary information matrixes in the non-transitory computer readable medium on the first network device, the plurality of summary information matrixes including: a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, wherein the HX information matrix includes a plurality of matrix information elements comprising: a chief complaint (“CC”), history of present illness (“HPI”), past medical, family, social history information (“PFMSH”) elements or review of system (“ROS”) information elements, wherein the PX information matrix includes a plurality of matrix information elements comprising: (“PF”) exam information for a general exam; an expanded problem focused exam (“EXPF”) a detailed exam (“DET”) or comprehensive exam (“COMP”) information elements, and wherein the CX information matrix includes a plurality of matrix information elements comprising: diagnosis (“DX”) or treatment options information elements including a straight forward (“SF”) diagnosis, low risk (“LOW”) number of diagnosis, a moderate number of (“MOD”) diagnosis or a high (“HIGH”) number of diagnosis and a plurality of risk (“RISK”) information elements including straight forward (“SF”) risk information, low risk (“LOW”) information, moderate risk (“MOD”) information or high risk (“HIGH”) information; for aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data from the first application on the first network device in real-time, wherein the aggregated medical data is aggregated into the plurality of summary information matrixes stored in the non-transitory computer readable medium on the first network device associated with the completed medical form; for calculating from the first application a plurality of medical and billing codes and a plurality of risk codes with selected ones of the plurality of matrix information elements from each of the plurality of summary information matrixes including the aggregated medical data accepted from the patient encounter; for creating automatically a new electronic medical record with a plurality of information fields in real-time via the first application on the first network with the aggregated medical data, the plurality of summary information matrixes, the calculated plurality of medical and billing codes and the calculated plurality of risk codes and a plurality of other summary medical information including: one or more medical and billing code modifiers, legal compliance for medical treatment provided to a patient during the patient encounter, an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter, a physician practice profile by aggregating data for a particular physician, an amount of time spent during the patient encounter; complexity risk information, laboratory and diagnostic test results completed during the patient encounter, data for use in research studies, and billing and invoice data; for providing in real-time the created new electronic medical record via the first application on the first network device for display on the GUI, thereby providing a complete 360 degree view of medical, complexity risk, billing, insurance and other information collected and generated from the patient encounter; for categorizing and limiting via the first application a selected number of medical diagnoses or medical management options in the created new electronic medical record, thereby reducing a medical risk and complexity associated with the patient encounter; for calculating a risk complexity value for the patient encounter from the categorized and limited created new electronic medical record; for extracting in real-time from the first application selected ones of elements from the categorized and limited created new electronic medical record and creating a summary information matrix for the patient encounter, wherein the summary information matrix limits an amount and complexity of patient data to be reviewed and a number of diagnostic options to be considered for the patient encounter; for displaying in real-time via the first application on the first network device via the GUI electronic information generated from the created summary information matrix and extracted from the categorized and limited created new electronic medical record and the calculated risk complexity value in one or more different colors than are used to display other electronic information from the created electronic medical record, thereby further reducing the medical risk associated with making a medical decision for the patient encounter using the displayed created summary information matrix; and for generating in real-time from the first application a patient invoice for the patient encounter via the categorized and limited created new electronic medical record and the one or more generated medical and billing codes for immediate presentation to the patient after the patient encounter, thereby reducing a risk and complexity associated with insurance billing and reducing a risk and complexity associated with collecting immediate payment from the patient after the patient encounter.
 20. The system of claim 19 wherein the one or more medical codes and billing codes include one or more of Evaluation and Management codes (“E/Ms”) codes, Current Procedural Terminology (“CPTs”) codes, Health Care Financing Administration Common Procedural Coding System (“HCPCS”) codes International Classification of Diseases 9^(th) Edition Clinical Modification (“ICD-9”) codes, or International Classification of Diseases 10^(th) Edition Clinical Modification (“ICD-10”) codes.
 21. The system of claim 19, wherein the one or more different electronic medical templates includes a plurality of electronic check-boxes including a plurality of different colors specifically selected for a specific type of medical practice, wherein processing the plurality of electronic check-boxes generates an appropriate number and type of medical and billing codes for the specific type of medical practice, wherein the plurality of electronic check-boxes include a plurality of different colors including a plurality of green and red check-boxes, wherein a green check box indicates medical personal examined the patient during the patient encounter, but the patient does not have any abnormality in a body area or body system indicated by the check-box and a red check box indicates the medical personal examined the patient during the patient encounter, but the patient does have one or more abnormalities in the body area or body system indicated by the check-box.
 22. The system of claim 19 wherein the one or more different electronic templates include one or more of an medical practice template, electronic invoice template, electronic medical record template, a current compliant template, a diagnosis template, a nurse template, a review template, or a provider template, wherein the medical practice template includes an electronic medical template for pediatrics, obstetrics and gynecology, cardiology, neurology, family practice medicine, emergency room medicine, walk-in clinics or urgent care clinics. 